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LIC WORKS PERMIT OPPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> OOL 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: 150'Z k C is{y' /qlO-'L C70221 <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? ❑ NO ❑ YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑ YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: 1�' V�7L( �v '-w <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 <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: CUt1e ti C <br /> OWNER MAILING ADDRESS: STREET <br /> CITY CAW STATE to ZIP C> CJ <br /> OWNER PHONE: — 1p— OWNER EMAIL: <br /> APPLICANT NAME: C / _ <br /> APPLICANT MAILING ADDRESS: STREET C) b <br /> CITY STATE ZIP i <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑ OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> ACKNOWLEDGEMENT.'1 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. 1 am the owner, or 1 am authorized by the owner of this property to <br /> perform the work for pplic n is made, and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PW t-7o <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) ) <br /> G <br />