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PISLIC WORKS PERMIT t#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: Z 9'a QJc er Avenve, E <br /> IF APPLICABLE: O LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:0 SFR-DETACHED 0 SFR-ATTACHED O DUPLEX O MULTI-FAMILY O COMMERCIAL O INDUSTRIAL <br /> CHANGE OF USE? NO O YES, FROM TO _ <br /> NEW WATER/SEWER SERVICE NEEDED? g NO O YES,TYPE_ SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK:+ I"g4,J ( o / r rt f G✓ a <br /> T Weil. 04t.JJ t,(1 W c/ it-i o t O 10Cdeal <br /> lR Ae- awe4 eq 1 44�' and (G Fuc4GA—V4 an o .4 At 4r 1Iart(. o-r e✓o <br /> O FENCE IN ROW FT IN HEIGHT <br /> 51,(It�lce � p,,_Mcdne01 vve 05 <br /> O DRIVEWAY APRON/CURB CUT FT WIDECon«tt Q✓t� <br /> 01 6e sealc� K/,�k <br /> O ASPHALT/CONCRETE PAVING SFac_��f eon Mdn�/ e✓��• <br /> O RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF r� <br /> �roC453 Inl;t► tilgeAy {tt(c.c. 3 days. <br /> O RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> O CLEARING/GRADING/FILL/EXCAVATE CY <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> O CUT/BORE IN PAVEMENT(NON-PARALLEL) 7, 4 <br /> CONTACT INFORMATION <br /> OWNER NAME: SkotAco Pam E <br /> OWNER MAILING ADDRESS: STREET p oe 12420 <br /> CITY .' + STATE W/9 ZIP 9(J ZQl <br /> OWNER PHONE: 2�- 26-2- SYOU 1OWNER EMAIL: <br /> APPLICANT NAME: j B <br /> APPLICANT MAILING ADDRESS: STREET 11r6 6A / 5treet, 5�,:te 3/ <br /> CITY YSq J, STATE W ZIP Q <br /> APPLICANT PHONE: 2S- 2?1 --3261 1 APPLICANT EMAIL: <br /> PRIMARY CONTACT: O OWNER 1� APPLICANT 0 OTHER (Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <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. l am the owner,or t 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 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />