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PSI II IA WORKS PERMIT i''LICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: `/Q?/- / St ,/Vc S' <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:XSFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX 0 MULTI-FAMILY DCOMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? II NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? I'NO ❑YES,TYPE SIZE <br /> SITE WORK//a lL RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: 1- S ! CL /1-7't ye,,7L eX(S-7[//;-7[//;,5/ d/is L1 <br /> Cory pf"o er-*f S/ T/^U 1--)/ode ( /y <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 /> rr�� <br /> X OWNER NAME: ` 41..‹. Let be <br /> OWNER MAILING ADDRESS: STREET ll L! l .t(/e <br /> F ^ 7 <br /> CITY (��' i'Lf �l� STATE (/L/� ZIP 7�L. <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: �7 2;S - 737 �/�'00 APPLICANT EMAIL: <br /> PRIMARY CONTACT: 0 OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: 1/14 -7 37 5`60 <br /> �C0 . 2 CONTACT EMAIL: 9)( ,427 ep,Z4Ct c e,„—, <br /> ACKNOWLEDGEMENT:1 ve reviewed 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 authorizes approved work and no deviations therefrom.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 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 /> PERMIT# <br /> 0� 2� i PW -70q -olf(c) <br /> Own A /T •' rized Agent Signature ate (Revised 10/12/2015) <br />