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. /7( /1f • PIOLIC WORKS PERMIT mWLICATION <br /> CITY OF EVERETT PERMIT SERVICES <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: 7Z <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 CI COMMERCIAL ONDUSTRIAL <br /> CHANGE OF USE? "6 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO CES,TYPE w / J�I`3IZE <br /> ' SITIE WONKA/R�IGH,T I WAY APPLICATION�INFORM►ATION <br /> DESCRIPTION OF WORK: /./t GC( j/ agat'i i - / /PL'l!/,r /iterG# <br /> /A1*/ LL ,cef <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT � FT WIDE <br /> ❑AAHALT/CONCRETE PAVING 3/OCe..-2 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: rA', 4-tre r- <br /> OWNER MAILING ADDRESS: STREET Pe, ejeific itzi f e �Qr /' <br /> CITY iit/td/ {> - STATE i ' ZIP 7a zw <br /> OWNER PHONE 4 '5 3 yy 5-5 �.. OWNER EMAIL <br /> APPLICANT NAME: PO!•!G'r WA/(//(l re041-- 64711471649.17r— /5 <br /> APPLICANT MAILING ADDRESS: STREET / 'Z.. <br /> CITY STATE 04 ZIP 710Z456 C <br /> APPLICANT PHONE: - - APPLICANT EMAIL: ` y ran <br /> PRIMARY CONTACT: 0 OWNER 0 APPLICANT4�OT Architect gineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: 22'eadrihficeAbill <br /> CONTACT EMAIL: 1IR ��� /V � ������,.,`_ <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 /> -/Z PW f - V ( O <br /> Owner/Autho ed Agent Signature Date (Revised 10/12/2015) <br />