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Pl� _IC WORKS PERMIT �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 � ww�r✓.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: � ! � �' °� �(�/�:���'' `� <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:OSFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? O ❑ YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? �NO ❑ YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> � <br /> DESCRIPTION OF WORK: ��CZV i�21( C�L �DL'4L`��/�cP� S 1��� <br /> � <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> �SPHALT/CONCRETE PAVING ! "( � . S S , t- 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: "�� G(GT��i �t �"���G£C� <br /> OWNER MAILING ADDRESS: srREET ( � ` Gl l�l S t�.�/�I� t� <br /> GTY ( G1jy(�. STATE _� ZIP �lJIL� � <br /> OWNER PHONE: ' -/ — �Z S �j OWNER EMAIL: (, ` f t' G�C,^1 '' %CCJYly1 <br /> APPLICANT NAME: ^"'� v U� � � . <br /> APPLICANT MAILING ADDRESS: sTREeT 1 L.( � G �>(��l/lf�1 v <br /> CITY � �f STATE ��� ZIP [���� <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ,�OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT AME: CONTACT PHONE: _ �.l g� �c'Z S � <br /> L �j' CONTACT EMAIL: c � l c�C�%Z7 <br /> �� ? 1 ' U ' �l ' ��1PI/ <br /> ACKNOWLEDGEMENT:1 have reviewed this application and confirm the information contain d rein is true and correct. lNork done pursu to this permit must <br /> comply with current federal,state, and local law. The granting of a permit only authorizes app d work and no deviations therefrom. Deviations must first be <br /> authorized in writing from the Building Officia/before being authorized under any circumstance. 1 am the owner, or/am autliorized by the owner of thrs 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 WfIC. <br /> �� City of Everett Official Use Only <br /> j. <br /> -''� ; PERMIT# <br /> , ,: � lt_ PW'U�liJ � l - ���� i <br /> `�� l s <br /> Ovy� Auth ized Agent Signature Date (Revised 10/12/2015) <br /> � <br />