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01.77_ PLIC WORKS PERMIT AllikLICATION <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 /> PROJECTrSITE INFORMATION { <br /> PROJECT ADDRESS: 2 e <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED El SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY El COMMERCIAL I=1 INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> 5FM . w,.,. x e . . *lati °Vfa GiltO!* ittgt9ATIO IN ORMAYIOK4 :.. I i MIQ* <br /> DESCRIPTION OF WORK: #.Gz � ®��`G�� t �'J <br /> \.- 4L,;C"�' l7 � an ou/dooK. S/`,r- afe®' o <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING SF <br /> O RETAINING WALL!ROCKERY IN RIGHT-OF-WAY LF <br /> O RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: 7 � G � ✓,�.� isup . ' <br /> OWNER MAILING ADDRESS: STREET / 1- / 7‘. <br /> CITY (,e/ c /74. <br /> // € V ' STATE C-"1/10&-- <br /> ,V/—�/�` ZIP <br /> OWNER PHONE: Z 7"��`��9 OWNER EMAIL: �GG ZG' /"=1 �-'—cr, G�1/1 <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET Z .-/1/7z, <br /> CITY STATE j�..� - ZIP <br /> APPLICANT PHONE: 4/Z ^,Zs _ T3 C APPLICANT EMAIL: Gc,r• <br /> PRIMARY CONTACT: 0 OWNER V,�APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: Z--/Z — - <br /> CONTACT EMAIL: L‘/ fie /.-e <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/ci,CL;c.., <br /> authorized in writing from the Building Official before being authorized under any circumstance.lam 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 /> e / PERMIT# <br /> Owner!FEatttorized Agent Signature to (Revised 10/12/2015) <br />