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<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 S1�'E 11dFORMATION
<br /> PROJECT ADDRESS: �� y l t �,'(� � S���C�C �
<br /> 1F APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.)
<br /> SITE WORK FOR PROJECT TYPE:C�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: L-�'l,l-n`��- -�J J',��(v�1 i ��t��,���1"' > (��'�� � �5 �� -
<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: � � � �'! C�I�C. C( '�
<br /> OWNER MAILING ADDRESS: sTReET � �tG1 � S 5+T�� {
<br /> CITY �� �.( �� STATE Y�/-�I ZIP � �����
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<br /> OWNER PHONE: � c�J � � G' Z OWNER EMAIL: S C� �S �� G�CP( / � vU/� �` �
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<br /> APPLICANT NAME: ✓- �GI C(` L��7�(���
<br /> APPLICANT MAILING ADDRESS: sTReET I l`'�L1 PS S�� ���� I
<br /> C17Y �1/� � � - STATE ZIP �` Z�
<br /> APPLICANT PHONE: ' �)� . APPLICANT EMAIL: �S �L. � �D � ��� %'7'1
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<br /> PRIMARY CONTACT: ❑ OWNER � APPLICANT ❑ OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NAME: 7r�Lj��, CONTACT PHONE: � � j�� -� �d
<br /> CONTACT EMAIL: j� P � `/, d r,r . �''�/y�
<br /> ACKNOWLEDGEMEIVT.�1 have reviewed this application and confirm the information confained herein is true and c �ect. Work ne pursuanf to this permit must
<br /> comply with current federal,state, and local law. The granting of a permit on/y 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 fo�which application is made, and I comply with the Sfate Contractors Law 98.27 RCW and 296.200A WAC.
<br /> Cify of Evereit Offrcial Use Only
<br /> PERMIT#
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<br /> Owner/Authorized Agent Signature Date (Revised 10/92/2095)
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