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POLIC WORKS PERMIT �WLICATION <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: 2-92- TH ?L ,511 Zo <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: I In -A Goh i A t <br /> IFO <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: k J�"G <br /> OWNER MAILING ADDRESS: STREET �i 3 Z 7H S hI <br /> CITY STATE W ZIP <br /> OWNER PHONE: U —Vq I OWNER EMAIL: Z-- <br /> APPLICANT NAME: PH L4 jh'KIt U <br /> APPLICANT MAILING ADDRESS: STREET M 0� <br /> CITY STATE ZIP <br /> APPLICANT PHONE: 20 6741 ( 1 APPLICANT EMAIL: <br /> PRIMARY CONTACT: 01 OWNER ❑ APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> PH 11,4 A 4 ) J ftG Ic CONTACT EMAIL: <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information containeV herein is trik and rdrject. Work done pLUuant 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 l 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 /> 07 02 � ► -� PWS � `( °� <br /> Owner/Authorized Agenti nate e Date (Revised 10/12/2015) <br />