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P LIC WOI�KS PERMIT PLICATION
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<br /> CITY OF EVERETT PERMIT St VICES
<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 SITE INFORMATION
<br /> PROJECTADDRESS: ]���� l-��.aa....�-( ��o�� J �^J��� °'� �fi �����
<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 /> � �
<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: M.���, 4�a,. �p�� -�a�, �v,�� y���� ��,�,��. � e�� �'�.�'a�� me�0���o me�
<br /> �. 6� — ma$ � a�s..$ �s�11 a+.�l �� L s.�-5�b'�: ,�u S , �/�.4a� alw�l$ �t.�_�a.�P ad�s,���-
<br /> �
<br /> an�+ e.e,�! �C�. a.ns� �a n.�N ,3� a� -�r N1 a�1l�v fl a�t� �"'. �� z�/�r��d Scs,ve.�
<br /> $m�'t+�sl's�
<br /> �FENCE�t§� "- Z$g) �F �µpaa,i s.a,�4�. � °�a FTINHEIGHT
<br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE
<br /> �ASPHALT/CONCRETE PAVING "�' �� �$�� SF
<br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF
<br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT
<br /> �CLEARING/GRADING/FILL/ XCAVATE '�- !�-� CY (,��--� ��-l�l �l�*� ���e �'`�`� �'��' ��P`�-'�
<br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF
<br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF
<br /> CONTACT INFORMATION
<br /> OWNERNAME: SaM tlo�r Er2C� n9£7tA� �sS& �2 � h�L�'�..I��as ��r � C,�at�c�.�..�r (�tFns,�
<br /> OWNER MAILING ADDRESS: srREEr '��i�.� ��,�+,.�,,�„��:�� ;�,�;^�� �,9.,'�"•��t
<br /> cirv �lg�s..`�f� srnTE �,�fh ziP '����.�
<br /> OWNER PHONE: ��25� ���'a ���'� OWNER EMAIL: ``�a 1d� �q��,�$-e.e c�s��, ��-
<br /> APPLICANT NAME: y'�`����a.. �d�S�l�.�
<br /> APPLICANT MAILING ADDRESS: srREEr �' �"�9c�� ��� 7�0. � �
<br /> CI1Y �`��+� STATE � ZIP ����
<br /> APPLICANT PHONE: ��a,��, � —��(,g> APPLICANT EMAIL: � ��,��,d�� � —�, ��y�
<br /> PRIMARY CONTACT: ❑ OWNER �APPLICANT ❑OTHER(Architect, ngineer, Etc.)
<br /> CONTACT NAME: CONTACT PHONE: ���� ��,,�. _����j
<br /> �,�-����-- �'����� CONTACT EMAIL: � ����,g��� ��,��
<br /> ACKNOWLEDGEMENT.�1 have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permif must
<br /> comply with current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations fherefrom. Deviations must first be
<br /> authorized in writing from the Building Official before being aufhorized under any circumstance. I am the owner,or I am authorized by the owner of this property to
<br /> perfo�m the work for which application 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
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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