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PUIC WORKS PERMIT AM 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: Mk( �� xbpc€ ave <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:DSFR-DETACHED DSFR-ATTACHED DDUPLEX DMULTI-FAMILY DCOMMERCIAL DINDUSTRIAL <br /> CHANGE OF USE? 0 NO 0 YES, FROM TO - <br /> NEW WATER 1 SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK;/ RIGHT-OF-WAY APPLICATION INFORMATION. <br /> DESCRIPTION OF WORK: <br /> E FENCE IN ROW 47 " IikkfPpC FT IN HEIGHT <br /> D 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 4FT IN HEIGHT FT TOTAL HEIGHT <br /> D CLEARING/GRADING/FILL/EXCAVATE CY <br /> D CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT.INFORMATION <br /> OWNER NAME: Sl .A�`l.C¢0 <br /> OWNER MAILING ADDRESS: STREET �/ t\ \ (,„,µ,`t,=,,,.1 ASJE <br /> CITY ( \J STATE it ZIP trzek <br /> OWNER PHONE: 4Z-6—2(^4714 S OWNER EMAIL: 4.p�/...J,.0kS*l a C'.C'�KR21kS'T'• C�J�Md— 1001 <br /> '.»_mw..,,,..,. ,,...,..... ..,�,.., _.r.,.... ,....: r.....,.,w. �_.,......._.�...,�. <br /> APPLICANT NAME: � z�V <br /> APPLICANT MAILING ADDRESS: STREET�j'` k 1 r� �Y <br /> y <br /> CITY �., STATE ZIP3z.„, <br /> APPLICANT PHONE LZS —Z3( _fig APPLICANT EMAIL: Y1A�Ip,.k.S 1�f G,e0 sr STS H <br /> PRIMARY CONTACT: .OWNER elErAPPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: 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.lam the owner,or 1 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 /> 4565- \ PW j o5 O3 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />