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PI®LIC WORKS PERMIT AOLICATION <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: 10911 Al lUoRT IZ-D <br /> IF APPLICABLE: ❑ LAND USE PROJECT# EP PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED E]SFR-ATTACHED ❑DUPLEX []MULTI-FAMILY COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? X NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? IH NO ❑ YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: ®h5 tA G o Glt( I 16j. <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT pp FT WIDE <br /> %ASPHALT/CONCRETE PAVING $� l S� SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> CLEARING/GRADING FIL /EXCAVATE ID CY <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: G <br /> OWNER MAILING ADDRESS: STREET ' I %Y' f <br /> CITY iJ fi�C/ A 418 ZO STATE ZIP <br /> OWNER PHONE: V.�j OWNER EMAIL: <br /> APPLICANT NAME: Int /� <br /> APPLICANT MAILING ADDRESS: STREET -`d,-!I A%"r 0 'A�» <br /> CITY V V�1 t� A (�/ STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑OWNER ❑APPLICANTOTHER rchitect Engineer, Etc.) <br /> CONTACT N E: �0.1\1TNTACT PHONE y 'J <br /> r27 2 215! <br /> yAri I ACT EMAIL: <br /> ACKNOWLEDGEMENT:l 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/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 /> A 16C PW <br /> Owner/Authorized Age t Signatur Date (Revised 10/12/2015) <br />