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PUBLIC WORKS PERMIT XPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />/► <br />PROJECT ADDRESS: Q RAP, (C kpt,C' A Vc-Nue � �2 W T <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI -FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br />IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # <br />UTILITY COMPANY'S NAME & JOB #: JOB # <br />`DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <br />FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />❑ FENCE IN ROW FT IN HEIGHT <br />❑ DRIVEWAY APRON / CURB CUT FT WIDE <br />PI ASPHALT / CONCRETE PAVING SF <br />❑ RETAINING WALL / ROCKERY IN RIGHT-OF-WAY LF r <br />❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIG I <br />❑ CLEARING / GRADING / FILL / EXCAVATE CY ��.99 <br />❑ CUT/BORE IN PAVEMENT (PARALLEL) LF a�t� <br />❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF CITY OF EVERETT <br />❑POLE WORK / AERIAL /OVERLASH LF Permit Servi;cp <br />ADDITIONAL DESCRIPTION (AS NEEDED): <br />CONTACT INFORMATION <br />OWNER / APPLICANT NAME: TfeavlmNm 10A/4L- 6ttaArL- try r <br />OWNER / APP. MAILING ADDRESS: STREET 321 (:p bN V15UE <br />C— CITY gE#tCCrr STATEWA ZIP96 20) <br />OWNER / APP. PHONE:/-/ Z�%� 41 <br />OWNER / APP. EMAIL: Av/ a G( AcI 10 b nov(oEN c6 • (7a($i <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LICENSE #(REQUIRED): <br />EVERETT BUSINESS LICENSE #(_REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER /APPLICANT ❑ CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: (���J <br />V <br />1>AVIU AQAG13 <br />CONTACT PHONE: yZS 2 — 7 �b _ ( Z <br />CONTACTEMAIL: o�Vl , . WAC�nO PRO1I{ Qifl%�• Q <br />ACKNOWLEDGEMENT.' I have reviewed this application and confinn 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 l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br />City of Everett Official Use Only <br />PERMIT # <br />�y PW of-oaP7 <br />Owner/Authorized Agent Signature Da e (Revised 1152017) <br />