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���ic ����� ��� i� �i���io� <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.govlpermits <br /> PROJECT SITE INFORMATIAN <br /> PROJECT ADDRESS: J� f� � I �� `� 1:.� � 1 G�'� /'� � �� � _�. t�% '`' <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:OSFR 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: <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> �ASPHALT/CONCRETE PAVING �(''S 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 � c��—> �/�/L�-�_. <br /> OWNER MAILING ADDRESS: srREEr l j� S� `1 � �l �` <br /> , ,� <br /> CITY � ._.._ STATE %��..,���`�.� ZIP i�„1� <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: sTReeT <br /> CITY STA7E Z�P <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:!have revrewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must <br /> comply with current federal,state, and local law. The granting of a permit only aufhorires approved work and no deviations therefrom.Deviations must first be <br /> authorized in wrifing from the Building Otficial before being authorized 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 i comply with the Stafe Confractors Law 18.27 RCW and 296.200A WAC. <br /> Cify of Everett Otficial Use On/y <br /> PERMIT# <br /> ,�,� ,�� �. � ��. � � 2 -�6 Pv� I ��o - 03$ <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />