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• �o���so� <br /> ������ w���� ��� �� �� <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 /> PiiOJEC'r SITE IINFORNiAT10Nl <br /> PROJECTADDRESS: �� � `�`' � �J=�.2=�'r ` �-� <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 NEE�7ED? ❑ NO ❑YES,TYPE SIZE <br /> SI'TE WOFLK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> C�FENCE IN ROW �_FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> CdASPHALT/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: � I`I <br /> OWNER MAILING ADDRESS: sTReer �z � t�l�- ' = <br /> - CITY � �,2� �'� STATE �� ZIP u� <br /> OWNER PHONE: '— � ,� � OWNER EMAIL: l� •' c% ` %Z - � <br /> APPLICANT NAME: �.�`��✓�(/ <br /> APPLICANT MAILING ADDRESS: sTREeT <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> ... ......... ,.,,,. __. . :.,... . <br /> PRIMARY CONTACT: �OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> ACKNOWLEDGEMENT.�I have reviewed this applicafion and confirm the informafion contained herein is t�ue and cor�ect. Work done pursuant to this pe�mit must <br /> comply wifh current federal,state, and local law. The granting of a permiP only authorizes approved work and no deviations theref�om.Deviations must first be <br /> authorized in writing from the Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to <br /> perform the work for which app/ication is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everetf Official Use Only <br /> PERMIT# <br /> ��,/�.�- �z s� 1� �VV 1�v � �Sj <br /> Owner/Authorized Agent Signature Date (Revised 10/9?_/2015) <br />