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PALIC WORKS PERMIT APLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: '6 <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? &KIO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? PONO ❑YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: a 7 L� /2v L h < F <br /> " Ob <br /> V / r>C <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF F <br /> El RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGH y� <br /> ❑ CLEARING/GRADING/FILL/EXCAVATE CY I <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF h"j913 z17 <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF O r f='s r <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> s4 <br /> OWNER MAILING ADDRESS: STREET 7—/ <br /> CITY STATE ZIP '9' O Z C <br /> OWNER PHONE:, S R -3y „ 02341; OWNER EMAIL: �C�� c'c/!/n.� 19 -611 Ca � , ,��'� <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREETu--- <br /> CITY �,�q'-�// STATE ZIP 7 <br /> APPLICANT PHONE: Z,5�-�,5� •J APPLICANT EMAIL: <br /> ......, <br /> PRIMARY CONTACT ❑ OWNERi'�HPPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAMEv"y,"<-.2, -Z CONTACT PHONE: <br /> CONTACT EMAIL: 77 <br /> ACKNOWLEDGEMENT.-I have reviewed this application and confirm the information contained herein is true and orrect. 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 Official Use Only <br /> PERMIT# <br /> PW 1-7-og <br /> Owner/Authorize nt Signature Date (Revised 10/12/2015) <br />