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PU _IC WORKS PERMIT A� i�LICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
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<br /> PROJECT ADDRESS: � � � - � , � - � � ; C. �'��.� '{'_ , .
<br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.)
<br /> SITE WORK FOR PROJECT TYPE:�SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO
<br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑ YES,TYPE SIZE
<br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION
<br /> DESCRIPTION OF WORK: ' • ,- , - . ' ;i ,, ' C' ' - , '
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<br /> ❑ FENCE IN ROW FT IN HEIGHT
<br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE
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<br /> �ASPHALT/CONCRETE PAVING � � ! ;, `.'' j;,..; ,^ . SF �- ',� � �' ,_ �,, � `,_' �;/ �� � i
<br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY ' LF
<br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT
<br /> ❑ CLEARWG/GRADING/FILL/EXCAVATE CY
<br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF
<br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF
<br /> CONTACT INFORMATION
<br /> OWNER NAME: }_- ; � , f� =;, ,:,_ •;
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<br /> OWNER MAILING ADDRESS: sTREEr � , � " "
<br /> CITY . , STATE � "��I�., ZIP '�•�..,�/ ��
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<br /> OWNER PHONE: �1 �� ' � � � � � �� OWNER EMAIL: '� � - - � ' �� `��
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<br /> APPLICANT NAME: � — .
<br /> APPLICANT MAILING ADDRESS: sTREET � -'_ !c � �•. �- �'�v �� = ��, ���' � �'��
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<br /> APPLICANT PHONE: '.'^ � \ APPLICANT EMAIL: `` - --, � . ^ �, , -�. ; • � •..�.,, - -,.„�
<br /> PRIMARY CONTACT: ❑ OWNER la APPLICANT [7 OTHER(Architect, Engineer, Etc.) � ' � - � '� !'' �
<br /> CONTACT NAME: . , CONTACT PHONE: ' '_' j' �,=� �- �; ��"�,`
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<br /> � CONTACT EMAIL: �v �,_i� _,. . ;t r'- �� ',i Ti�_ � •- „ ,�2 � � ���,. �
<br /> ACKNOWLEDGEMENT:1 have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must
<br /> comply with current federal, state, and local law. The granting of a permit only authorizes approved work and no deviations therefrom. Deviations must first be
<br /> authorized in writing from the Building Official before being authorized under any circumstance. I am the owner, or I am authorized by the owner of this property to
<br /> perform the work for which application is made,'and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> � , City of Everett Officia/Use Only
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<br /> j PERMIT#
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<br /> Owner/Authorized Agent Signature f Date (Revised 10/12/2015)
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