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P LIC WORKS PERMIT _ PLICATION
<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 /> .. ._. _,.. _ .. .. ._. .. ..>h.. -X ,.._..��`. .,r s-n_to-z. . . .x.'�v,4 ...<.,. ..-.,.. _:,,. ,.
<br /> PROJECT ADDRESS: 2-3.37- f,k.P-r/ ,4
<br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE APP,SS, ETC.)
<br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED 0 DUPLEX 0 MULTI-FAMILY ID COMMERCIAL 0 INDUSTRIAL
<br /> CHANGE OF USE? ❑NO D YES, FROM TO
<br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE
<br /> $ITE.WORK/ RIGHT-OF-WAY;APPLICATION INFORMATION;
<br /> DESCRIPTION OF WORK:
<br /> FENCE IN ROW 3• FT IN HEIGHT
<br /> ❑ 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 /> ❑ CLEARING/GRADING/FILL/EXCAVATE CY
<br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF
<br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF
<br /> CONTACT INFORMATION
<br /> OWNER NAME: / e� /�7
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE 2 6"-2 7g-77 OWNER EMAIL: ,./K �1
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<br /> APPLICANT NAME:
<br /> APPLICANT MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> APPLICANT PHONE: APPLICANT EMAIL:
<br /> PRIMARY CONTACT: WNER ❑APPLICANT ❑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.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 /> 9/3/67- PW 1"9-0
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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