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047T Pt-IC WORKS PERMIT A'LICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT;SITE INFORMATION <br /> PROJECT ADDRESS:5209 EVERGREEN WAY <br /> IF APPLICABLE: o LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE: O SFR-DETACHED O SFR-ATTACHED O DUPLEX O MULTI-FAMILY O COMMERCIAL <br /> CHANGE OF USE? O NO O YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? O NO O YES,TYPE SIZE <br /> SITE WORK%:RIGHT-OF-WAY.APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: REPAVING PARKING LOTy �4 Ovsti any <br /> y <br /> O FENCE IN ROW FT IN HEIGHT <br /> O DRIVEWAY APRON/CURB CUT ��q9 FT WIDE <br /> ASPHALT/CONCRETE PAVING N �V�COO SF <br /> O RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> O RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> O CLEARING/GRADING/FILL/EXCAVATE CY <br /> CI CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> CI CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: JSH PROPERTIES <br /> OWNER MAILING ADDRESS: STREET 10655 NE 4TH ST.SUITE 901 <br /> crw BELLEVUE STATE WA ZIP 98004 <br /> OWNER PHONE:4256790525 'OWNER EMAIL: jimf@jshproperties.com <br /> APPLICANT NAME: PACIFIC PAVEMENTPROTECTION(P3) <br /> APPLICANT MAILING ADDRESS: STREET 19827 23RD DR SE <br /> cry BOTHELL STATE WA ZIP 9801 <br /> APPLICANT PHONE: 2067608600 (APPLICANT EMAIL: brute@p3nw.com <br /> PRIMARY CONTACT: O OWNER O APPLICANT O OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: BRUCE FREEBURY 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 I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PW1704-037 <br /> Auth. ed Agent/Owner Date (Revised 10/12/2015) <br />