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P�LIC WORKS PERMIT A�PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits <br /> �� �"�� ��PROJECT SITE INFORNIATIOhI ������ ��� ` ��� <br /> ��� .���, �� �:.� ���� f�_�, �,_ - <br /> . , ,a . � _ , x P :��.. .. <br /> � <br /> PROJECT ADDRESS: ��i D �I��� P� � E ��Q(�Q � � <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:�SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? �NO ❑YES,TYPE SIZE <br /> ' ' ' SITE WORK% RIGHT OF;WAY'APPLICATION INFORMATION: , <br /> : r <br /> 3 9. <br /> DESCRIPTION OF WORK: 1 <br /> �12� �! �t ' a.�`� � � � � � <br /> � ov �, - 5 <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`INF.ORMATION <br /> OWNER NAME: �P.1�I �(.l, B7Q I �UY _ <br /> OWNER MAILING ADDRESS: srReEr i Q�`� (.� �j� <br /> CIN V�G 1 STATE �� ZIP �()L.�/ <br /> OWNER PHONE: �'/ZS � � � `a� OWNER EMAIL: �� I ��Gi. �M� <br /> APPLICANT NAME: �Y�i1� � <br /> APPLICANT MAILING ADDRESS: sTReeT SG�1 f IQ (o't S �Q�� <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: OWNER ❑APPLICANT ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: � CONTACT PHONE: Z ,, ,�`T�,` 3J`�� <br /> �r�Q� G�W/�i�,( CONTACT EMAIL: � f� Q � � � � � ' ��' � C� <br /> ACKNOWLEDGEMENT.•1 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 musf first be <br /> authorized in writing from the Building Official before being authorized under any circumstance.1 am the owner,or I am authorized by the owner of this property to <br /> perform the work for which application is made,and 1 comply with fhe State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> _ � �5 �-o/-� PW /,60� �- 0 36 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />