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• PUU�..IC 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 /> •_ ��-� �` ����` ��'� ��`;;-�.� _PROJEC�T�SITE�INFORMATION��� h�;,�� �.� � ��,� ����
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<br /> PROJECT ADDRESS: L, � �.
<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 USE2 ❑ NO ❑YES, FROM TO
<br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑YES,TYPE SIZE
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<br /> �;��*���>���i��;���,a��;. �����S�,T� . ORK/�R�1GHT OF�Y�APPLIC $TIO �INFO� A , �� '���`„' ',�'��'�'�� �.-�
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<br /> DESCRIPTION OF WORK:
<br /> � FENCE IN ROW jp� 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 4FT1N 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 /> �'} T �, � CONTACT INFORMATION , �� ` 4 � ' Y ` _`
<br /> sA� i .Ci. a.-�.: �4
<br /> OWNER NAME:
<br /> OWNER MAILING ADD S: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: � ' OWNER EMAIL:
<br /> APPLICANT NAME: Q �� — '�.
<br /> APPLICANT MAILING ADDRESS: sTReEr � �
<br /> CITY�V Y STATE ZIP`(O
<br /> APPLICANT PHONE:u – � APPLICANT EMAIL: •
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<br /> PRIMARY CONTACT: ❑ OWNER �APPLICANT ❑ OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NAME: CONTACT PHONE: L��S– `7(-� (!�
<br /> CONTACT EMAIL: y�
<br /> ACKNOWLEDGEMENT.�1 have reviewed this application and confirm the information contained herein is e and correct, rk 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.l 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 Contracfors Law 98.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> � ; PW 1�03- �6�
<br /> ,-
<br /> n / utho ed Agent Signat Date (Revised 10/92/2015)
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