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PL LIC WORKS PERMIT Al�'LICATION
<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 /> �� ��� �`� ��,� °`� � �PRO�JEC�� S7TE�I�IFORMATION ��' �� �,��y} n=� ��`"�''
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<br /> PROJECT ADDRESS: .�'OQ,� S! D G
<br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.)
<br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATfACHED ❑DUPLEX ❑MULTI-FAMILY C�COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? I�NO ❑YES, FROM TO
<br /> NEW WATER/SEWER SERVICE NEEDED? �,NO ❑YES,TYPE SIZE
<br /> ' �`.. � ���t ��.� �<<L�� ��^ SI-TE�W' 'l:R1�GHT AF�YIf/kY A £ LIC TION�INFOR M TION� ��� 3� '��� �� ,,.�
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<br /> DESCRIPTION OF WORK: S I L. p U S u J�G�t,7'"S(,�Q ,�1L o/J �'1h. 0•!�LJ
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<br /> ❑ FENCE IN ROW ' ,FT IN HEIGHT
<br /> ❑ DRNEWAY APRON/CURB CUT FT WIDE ��5,� �f �� lOt O�c�
<br /> g0_�o -�,� ne� tqaoac�
<br /> ❑ASPHALT/CONCRETEPAVWG SF t � �� n��Q�0eF9�
<br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF � ��� A.�af e6G�
<br /> �$�� � ��K+!'_'•
<br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT
<br /> �CLEARING/GRADING/FILL/EXCAVATE � �j�.���! CY, , �(�5•�
<br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF
<br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF .
<br /> ��:;. ° �� .��; ; n.: � < CONTACT�INFj,ORMAT10�1 r. F` , :s �, -� ��,. <:
<br /> OWNER NAME: a
<br /> OWNER MAILING ADDRESS: sTReeT j 00� L1J3� S��.tb
<br /> ��'ry v STATE ZIP '�/ D � /
<br /> OWNER PHONE: oZ S" ,Z3�'61g g OWNER EMAIL: . � � p
<br /> APPLICANT NAME: J �
<br /> APPLICANT MAILING ADDRESS: srReeT S.a�7j?G
<br /> � � � � CITY � � STATE � 21P � � ��
<br /> APPLICANT PHONE: �,5-°.Z3$-61�/S APPLICANT EMAIL: � • (�' -�U�J�fG�-' BG,LIb/�•�I"'`
<br /> PRIMARY CONTACT: ❑OWNER PPLICANT ❑OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<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,or I am authorized by the owner of this property to
<br /> perform the work for which application is made,and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> ,-��-�� PW1��L -�i�
<br /> Owner/Authorize Agent Signa ure Date (Revised 10/12/2015) f�
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