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PUBLIC WORKS PERMIT APPLICATION <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 I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: (�� c{ I �JZ YC (+♦ O\ <br /> IF APPLICABLE: ❑ LAND USE <br /> ��PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE--9SFR-DE-rACFIED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL. <br /> CHANGE OF USE? `Yil NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? -'-E7 NO ❑YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> &S CL. \c. C`i C�c�l Gi �1z. . <br /> FENCE IN ROW 3 Z LtA+U 4 S1C(S. FT IN HEIGHT <br /> �X Z� b��c,+� v� 5►d-e u� <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY <br /> ❑CUT/BORE 1N PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET Lc <br /> CITY Evc-e STATE ZIPT( o <br /> OWNER PHONE: 31 1 - C1 U07 OWNER EMAIL:j <br /> APPLICANT NAME: M C <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> :....-_.... .:... .. ...__...... ......_ ,......:....._...... .. ......... .. ... ........_.. .,..: <br /> . ...................:............ <br /> PRIMARY CONTACT---EOWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: 121(-v(-v-3 - 1 - 9 cLI 7- <br /> Jc a) E-W-011 CONTACT EMAIL: jX�LL, tnt7uo c ,t <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 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 170b --050 <br />