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4vE77 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 I www.everettwa.gov/permits <br /> ?ell PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: �� 1'310-0 W A- <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS,ETC.) P Imo) ^'OO <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX 0 MULTI-FAMILY OCOMMERCIAL DINDUSTRIAL <br /> CHANGE OF USE? ❑ NO YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION,INFORMATION <br /> AIDZIOMINEMI <br /> DESCRIPTION OF WORK: pail() Il;lkA. 6w--t' - t-s ,*.j P <br /> (' vim► o1= P6 -iki '1:5 A-5P W ' k- i..,o-r uu\-t--4 <br /> 2ice, � t c <br /> o FENCE IN ROW FT IN HEIGHT <br /> DRIVEWAY APRON/CURB CUT I It FT WIDE <br /> KASPHALT/CONCRETE PAVING 1 106 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: WA S NiN61 '57A- 1,9,1\iI '-G.Vrt ' <br /> OWNER MAILING ADDRESS: STREET Wit& Vi 2-01 ` .CN'i 6Pe ) \ c' ' " "�}(-z <br /> CITY 1V(. STATE V VIC ZIP q a 6 e5`(` <br /> ✓ <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: 6A'A �tA 1 <br /> APPLICANT MAILING ADDRESS: STREET (fit' }ANS i O 1 �i,l � <br /> Crry li° ` l/v STATE WA- ZIP q0 101 <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: 0 OWNER APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: 2,00 -- 61-73 .- 1 4961.3 <br /> CONTACT EMAIL: ( f7(/i *A-1-0 r'0. 5 1 PSN ,J t i <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.1 am the owner,or 1 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 /> 41111.."- pw(6,Qx., _ 0 3/ <br /> Owner/Authorized Agen""' • ure Date (Revised 10/12/2015) <br />