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- i Curran Coos+V` eon -SttEt <br /> Aow PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov"l www.everettwa,gov/permits <br /> PROJECT SITE INFORMATION <br /> � r ,..t ,.�.>. � sx. u.,�._..� �_�:.. C , gip. <br /> PROJECT ADDRESS:. A,,L^)\ C�L�C Y r� '� �� . �5 dere , , h W` CN9rA0 r <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:DSFR-DETACHED ❑SFR-ATTACHED ID DUPLEX ❑MULTI-FAMILY PEOMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? NI NO 0 YES,TYPE . SIZE <br /> SITE WORK I.RIGHT OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: �C�(ZC -j\�(� ICY U`C-1 <br /> Q <br /> )v\.*PQ -R(D( 5.�€ <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE r e <br /> El ASPHALT/CONCRETE PAVING � <br /> i'vlz <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY C'{/1,t dOrie r% <br /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGF 4yyjtjr Iv,'o 9` HEIGHT y , <br /> ❑CLEARING/GRADING/FILL/EXCAVATE _ S (° 106 7z <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) K,r k j <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) ^ ALS CSS <br /> CONTACT INFORMATION <br /> OWNER NAME: y-1-11 _s,c kC9_S.-Nch Qn C_ \01r-crc m\C\ <br /> OWNER MAILING ADDRESS: STREETIti ° 'C Cly <br /> S`s�.�e.� LOG-0,-- Q, Q <br /> CITY ,��? STATE k ZIP C J <br /> OWNER PHONE +{3�J-1f --,JIOWNER EMAIL <br /> APPLICANT NAME: \.. <br /> APPLICANT MAILING ADDRESS: STREET , '6ISC:Y2) \ \ ••,Q 1ULC� p `-y�Q� <br /> CITY <br /> STATE t��A ZIP —\O `U <br /> APPLICANT PHONE: _ 9 `t\Q 0\ ` APPLICANT EMAIL: \0\00\-k C cv\- � C .cC 1 <br /> PRIMARY CONTACT: 0 OWNER a-APPLICANT OTHER(Architect, Engineer, Etc.) \`Cl. i ( Ci�r't 7c cc") <br /> CONTACT NAME: CONTACT PHONE: t1�, <br /> rcNe\0 \Accotyr CONTACT EMAIL: <br /> s-)10,Y`f1� CA'7 el Qok\C11 c\\-- <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.I am the owner,ori 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 /> PPEERMIIT/# <br /> 1 !1V <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />