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PLIC WORKS PERMIT PLICATION <br /> CITY OF EVERETT PERMIT SL VICES <br /> 00 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 SITE INFORMATION <br /> PROJECT ADDRESS: -11 <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:NSFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? IS] NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ISI NO ❑YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: .,� W �iA^/ j Errs `'✓ (� �z <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: ( _ <br /> 7-4 <br /> OWNER MAILING ADDRESS: STREET / 3 0— L <br /> CITY i r, STATE ZIP 0_3 <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: L <br /> APPLICANT MAILING ADDRESS: STREET 72'7L)7 v7,r, <br /> CIN / /� STATE ZIP <br /> APPLICANT PONE:. �j APPLICANT EMAIL: l� <br /> LI H <br /> �J r� <br /> r � u.., _........ ......_v. <br /> PRIMARY CONTACT: ❑ OWNER 4 APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL. <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 1 am authorized by the owner of this property to <br /> perform the work for which application is made,and 1 comply with the State Contractors Law 98.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> C) 0 <br /> Owner a thorize Agent Signature Date (Revised 90/92/2095) I <br />