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P63LIC WORKS PERMIT #PLICATION <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 www.everettwa.gov/permits <br /> PROJECT R <br /> SITE INFOMATION <br /> PROJECTADDRESS: IBJ TORN O <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED WDUPLEX ❑MULTI-•FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑ NO 4M YES, FROM S T:f TO <br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑YES,TYPE SIZE <br /> SITE WORK I RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> ❑FENCE 1N 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 <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> ❑ CLEARING/GRADING/FILL/EXCAVATE CY <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT;INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET Z-Oq D Z C7 -7 'kfz A/CZ <br /> CITY r 5.\j-\ `\K- STATE _ ZIP D ZL3 <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> C1TyN_`\ani S V 1kc STATE: Cx - ZIP 9 Q <br /> APPLICANT PHONE: JAPPLICANT EMAIL: �Qx-_V I/1GlClJprl< <br /> PRIMARY CONTACT: ❑ OWNER {APPLICANT ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: {1,�,,,. CONTACT PHONE: g�- Zef0-2- 25 <br /> '�cse l t-'F�.cv CONTACT EMAIL: �o-e� e lna.qc bro4-k4 rS. c d•^i <br /> ACKNOWLEDGEMENT,/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 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 1605 -0"�o <br /> Owner ut orized Agent Signatu Date (Revised 10/12/2015) l <br />