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PI�LIC WORKS PERMIT A�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
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<br /> ��� ���� �`� 1 � �� �.����,.���� �PROJECT�SITE�INFOR�VIATION t��� ��� �� ��� �� � � � � � ��
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<br /> PROJECT ADDRESS: ��� CYZ°��`CVt C'-tl�U ��'���
<br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.)
<br /> SITE WORK FOR PROJECT TYPE:�SFR-DETACHED ❑SFR-ATfACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? NO ❑YES, FROM TO
<br /> NEtN WATER/SEWER SERVICE NEEDED? NO ❑YES,TYPE SIZE
<br /> ,�;�,�� � } �, r�- F �,,.�4.���,-„�.�.� �„� .�....:,Yv„�, ���;� PLIC�ATIO�N�;�NFO�R��M�I�O�,�.N�.�,����}���� �F� , �^, � � :�:�:.
<br /> .�<_ , , :, �� < � SITE WORKf/ RI,GHT�.,OE,�,U�tAY�,A,,,,���, �
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<br /> DESCRIPTION OF WORK: ry`{'Yln(} GZ S G(C1C� ` � S
<br /> ❑ FENCE IN ROW FT IN HEIGHT
<br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE
<br /> ❑ASPHALT I CONCRETE PAV(NG 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 /> � 4 CONTACT INFORMATION `z� _ ,
<br /> OWNER NAME: QK� G�U�'�A
<br /> OWNER MAILING ADDRESS: sTReET c3 ) � S C
<br /> CIN �� STATE a Z�P g Z�3
<br /> OWNER PHONE: �"'a S' J�3O' 3 OWNER EMAIL: Qfj � oL C �G C �"�
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<br /> APPLICANT NAME: Q�'l11 ('j1{J�
<br /> APPLICANT MAILING ADDRESS: srReeT � 5 a vv�e as G�'j�N�.�
<br /> CIN STATE ZIP
<br /> APPLICANT PHONE: ZS- a 3- D 7 (� APPLICANT EMAIL: �dl.c n ��y�t1�-e �V C� G{,�GO, �AVI/�
<br /> PRiMARY CONTACT:Y OtOWNER��APPLICANT ❑OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NAME: CONTACT PHONE: ^�—�---�—� yaS' cj 2.3 - U� �i
<br /> ��� � �� CONTACTEMAIL: J��N G � � Q, "
<br /> ACKNOWLEDGEMENT.�1 ha e reviewed this application and confirm the information contained herein is true and c rrect. Work do e pursuant to this permit musf
<br /> comply with current federal,sfate,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 Officia!before being authorized under any circumstance.I am the owner,or 1 am authorized by the owner of this property fo
<br /> perform the work for which application is made,and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> y1231�
<br /> PW ��5 '��'�
<br /> Owner/Authoriz d Agent Signature Date (Revised 90/92/2015)
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