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/11111°":4 <br /> PUtLIC WORKS PERMIT ANDLICATION <br /> < I*►' 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 j www.everettwa.gov/permits <br /> PROJECT SITEINFORMATION <br /> PROJECT ADDRESS: 1,,c1 ©lio <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PR APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED 0 DUPLEX 0 MULTI-FAMILY .ICOMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK L>RIGHT OF,WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> 0FE FENCE IN ROW FT IN HEIGHT <br /> ELJ DRIVEWAY APRON/CURB CUT a. )( l r 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: <br /> OWNER MAILING ADDRESS: STREET I vez 4j. s, 7 7 7-11. )fit v --' ��r---yyy <br /> CITY Arm TZ_.G� STATE WQ ZIP 1 V 6 7 <br /> OWNER PHONE. �! OWNER EMAIL: <br /> KH,M .M.H,. ._. .. a,. ..n.,.— r., .�. <br /> APPLICANT NAME: y todciR,Feil9fr' C-1 J tki <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE:tgago2,172g.p APPLICANT EMAIL: ��NM <br /> PRIMARY CONTACT: 0 OWNER 0 APPLICANT 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.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 /> -2_71 7PW (9-08-018 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />