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PI�LIC WORKS PERMIT A�'LICATION
<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 SITE INFORMATION
<br /> PROJECT ADDRESS: �f s;-,- ��� �E � =�. �;. .-, < ', %1 l � �G��I
<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/SEVI�FR SERVICE NEEDED? �I NO ❑ YES,TYPE SIZE
<br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION
<br /> DESCRIPTION OF WORK: � �; ° "„ ` — ,.:� . ,-� � �� , � C.�, � 'F
<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: � �� ��p_.e� �,i.�
<br /> OWNER MAILING ADDRESS: srREET � -; � ;� -� � �
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<br /> CITY /�"'_--•.f ,a`;'... STATE '� ZIP
<br /> _ ')/`� �} � i
<br /> OWNER PHONE_ ��E' `�> � �� �'`� :��5 OWNER EMAIL: ,'u:.I�,..��t �-z-i.2 �•1 � r � .,G,.w._..; , t.
<br /> APPLICANT NAME: ` r��� t S �� ��t. 4 'r,'
<br /> APPLICANT MAILING ADDRESS: sTREer �:� ? � ��•�,,
<br /> CITY .Lt,,a �?.'�d�` .. STATE I�%'��� ZIP ;f%'_-�;� �c.;
<br /> APPLICANT PHONE: '�f�'•,y�'` -� �.`� APPLICANT EMAIL: ��r;.i-�.� - r- � c:' ` -�.-- ����' �i-,'�'. �. ';
<br /> PRIMARY CONTACT: ❑ OWNER �„APPLICANT ❑ OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NAME: CONTACT PHONE: � ,e � —� �_ 4 �
<br /> ' _.� . ��—e
<br /> �e'7..�.'`, �..� c a,.��i �'�'`;'t CONTACT EMAIL: �.,,w�,l_ � -,�,.�,.' -'t. G ,i f ��, ,�
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<br /> ACKNOWLEDGEMENT. I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant fo this pe mit must
<br /> comply with current federal,state, and local law. The granting of a permit only autnorizes approved work and no deviations therefrom. Deviations must first be
<br /> authorized in w�iting 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 which app/icafion is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> Crty of Everett Official Use Only
<br /> , /� µ PERMIT#
<br /> '� ; « ��s- ola
<br /> �� , r C , r i��; j� PW
<br /> Owner/Authorized Agent S` ture Date (Revised 90/12/2015)
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