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P�LIC WORKS PERMIT �PLICATION <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 /> PROJECTADDRESS: �"� �� -�� � ;��Z,����L� �%�i' ;�� ';- � . ��G:� <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ��.p�(IULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? j�l NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO "'�,YES,TYPE �'—Y"�� � /Z�� 2"�� SIZ�E��� �Tl�' <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: �D�G�`�/�/Gi/ l��/�/ c�� i4 `j�,�`'I �Gl� O/V�� <br /> ���-���`�/i G��/�L%�� Go i37Ni��%r . ��Sij�,�i/��� C��.'��S <br /> �23 f3�5 ��- /���-�% � �Si�� � �'��/�-�', - <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: - ' ����;���� . , L_ <br /> OWNER MAILING ADDRESS: sTREET ` �/1/�' �-'`J /j'-% , lj/ ' '' <br /> CITY ���� STATE ZIP `� �� <br /> OWNER PHONE: ,��� - Z,'�j� �l�� OWNER EMAIL: I�i =' % �'� /�(jJ��NI- , Qf•i.'( <br /> APPLICANT NAME: ' ,/L�''� <br /> APPLICANT MAILWG ADDRESS: sTReer <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: �OWNER ❑ APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: ��� , -��" • ��� <br /> ��/l//✓t ��✓i�L�L�t"'�- CONTACT EMAIL: ^ c�Ul rLL"���� E_' C/� .� L�G�'✓� <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contai d herein is true and correct. Work done pursuant to this permit must <br /> comp/y with current federal,state,and local law. The granting of a permit only authorizes approved work and no deviafions therefrom. Deviations musi first be <br /> authorized in writing from the Building Official before being authorized under any circumstance. 1 am the owner,or I am authorized by the owner of this property to <br /> perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> � <br /> PERMIT# <br /> %�`=����`�L,�' , � � � PW 1�D � -�D� <br /> O erlAuthorized Agent Signature Date (Revised 10/12/2015) <br />