Laserfiche WebLink
JBLIC WORKS PERM! APPLICATION <br /> 1.111CITY OF EVERETT PERMIT SERVICES <br /> `'M 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 3ZOZ_ A/Or'7tOM 4v <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:%SFR-DETACHED ❑SFR-ATTACHED CI DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? MNO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 'NO 0 YES,TYPE SIZE <br /> SITE WORK/RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: Ins 4-4 a re +at1)h0Y1 toe at /Yf Ct�Tt/ <br /> RI 4 11+ OF' %4f `y <br /> Waif <br /> ht& I pro- »c�� 4 .�— <br /> N ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> J`1 RETAINING WALL/ROCKERY IN RIGHT-OF-WAY 4-f f'_ 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: Dea r Ie.L Lev, se: <br /> OWNER MAILING ADDRESS: STREET 3202-- rwfon At/e <br /> CITY EYe.h tit STATE 4 ZIP F920 � <br /> OWNER PHONE: 808 - 987 2I 7 Li OWNER EMAIL: <br /> APPLICANT NAME: S1 c7n e /T • <LI Cl f �{-- <br /> �✓� <br /> APPLICANT MAILING ADDRESS: STREET 3-7 ZO S /C.t Z 5 / o <br /> CITY I L STATE C�l ZIP ifs O <br /> APPLICANT PHONE 3b 2317-0623 APPLICANT EMAIL <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.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 I l WADb' <br /> WAW <br /> y of Everett Official Use Only <br /> PERMIT# <br /> rg//7. MWV / I'l "W\ <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />