Laserfiche WebLink
PUBLIC WORKS PERMITAil rLICATION <br /> Ntigy 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 INFORMATION0. w... .Fw_.. <br /> PROJECT ADDRESS: 3 l O k A (AA b ci d2 <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:IDETACHED ❑SFR-ATTACHED ❑DUPLEX 0 MULTI-FAMILY 0 COMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? O2'NU ❑YES, FROM TO <br /> NEW WATER!SEWER SERVICE NEEDED? C7-I 15 0 YES,TYPE SIZE <br /> SITE WORK'/ RIGHT OF WAY APPLICATION INFORMATION <br /> nn <br /> DESCRIPTION OF WORK: d GK ro� N o 4 <br /> .,� I -ref) e <br /> ❑ FENCE IN ROW / 14 f/ FT IN HEIGHT <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF ' \\,,, I,s l I <br /> s . Imo. <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF 1r,=. '.l V LI=I 1 <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY k <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF CITY O EVERETT <br /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Permit Services <br /> • f CONTACT INFORMATION <br /> OWNER NAME: (Dc 0 �c\-e.-el— <br /> OWNER MAILING ADDRESS: STREET <br /> CITY 64-8-143 )e, n y ` ? STATE QV•cres • ) ZIP <br /> OWNER PHONE: 5-2-t 1 __3 9q` OWNER EMAIL: <br /> APPLICANT NAME: \-<(,(_,(-IA ``\e co. (r-CIL (�r� i <br /> APPLICANT MAILING ADDRESS: STREET �, j� lb $q7 T v` 1� CrCITY L _ • e U' .s STATE (1U C ZIP c( 5 3 <br /> APPLICANT PHONE:Z--k 5-344:2-LH�3 ( APPLICANT EMAIL: <br /> PRIMARY CONTACT: 0 OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: o:16,44,,u4 <br /> (---„2._(pa CONTACT PHONE: <br /> 42 t5 °--5 4-(j z4—l. ( CONTACT EMAIL: 1----a../1(..)-e.�4 "1. Lc ®C1 j� ( ,C aK <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 /> PVI! /9V--- osd <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />