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OLT P ILIC WORKS PERMIT Hi IPLICATION <br /> CITY OF EVERETT PERMIT VICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: (4 ( / �� LI 01 /AUS edc;e t f i L., 4 `1 Z C <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COM MERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? 0 NO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> FENCE IN ROW 4/2 I f 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 /> 0 CLEARING/GRADING/FILL!EXCAVATE CY <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: \mac <br /> OWNER MAILING ADDRESS: STREET 2.c/ lilt- c-{f <br /> CITY 1:-.7 L,, C"'Q STATE LJ A <br /> ZIP 9 <br /> OWNER PHONE: 2 } 3 V OWNER EMAIL: 1 �; u L4 Cy d� h J ( o'er <br /> APPLICANT NAME: c6( { `J <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: t..1d'UWNER El APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: 1 CONTACT PHONE: L/ 2 S 3 L' t, , 13-7 <br /> Se. (4 Oot v--r- I S CONTACT EMAIL: 3 at-)Lcur S y 4 ( <br /> ACKNOWLEDGEMENT:I have 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. lam 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 /> 1���— � <br /> Owner/ ut ori d Agent Signature Date W-Cl, 1 1� PW e� <br /> (Revised 10/12/2015) <br />