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PLIC WORKS PERMIT 'PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 3 L `r <br /> IF APPLICABLE: 171 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? L9 NO ❑ YES, FROM TO <br /> NEW WATER I SEWER SERVICE NEEDED? NO ❑ YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION Oi- WORK: <br /> 71 F 114x_ ,4c 7-:-P <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON /CURB CUT FT WIDE <br /> El ASPHALT/CONCRETE PAVING SF f <br /> N >~ tjrr <br /> El RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> 1:1RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HT Sip 0 9 2016 <br /> LD <br /> ElCLEARING/GRADING/FILL/EXCAVATE CY <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF CITY OF EVERETT <br /> Permit Services <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: Nu- <br /> OWNER <br /> MAILING ADDRESS: STREET G 147' 'J s v IT <br /> CITY STATE WA ZIP ego/ <br /> OWNER PHONE: �}Zro- ^ &-I?q 1OWNER EMAIL: <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET Z 0A r-S AV ejj vr- <br /> CITY V STATE/ Wyk ZIP zz / <br /> APPLICANT PHONE: - 2 - ��®8 APPLICANT EMAIL: (44 e-S 1,kktCLe-c' . CGwi <br /> PRIMARY CONTACT: ❑ OWNER TrAPPLICANT ❑ OTHER (Architect. Engineer, Etc.) <br /> CONTACT NAME: Al a455 W42-KE:ie- CONTACT PHONE: <br /> CONTACT EMAIL: l�lZ�CS �j{�l�GLY� COPP', <br /> ACKNOWLEDGEMENT:I 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 l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PW c-1 �;? I <br /> Ow r/Authorized Agent Signature Date (Revised 10/12/2015) <br />