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PUISLIC WORKS PERMIT 11rPLICATION
<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: IL( Co\\y A t-V ett LutP
<br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.)
<br /> SITE WORK FOR PROJECT TYPE: i?SFR-DETACHED ❑SFR-ATTACHED El DUPLEX 0 MULTI-FAMILY ❑COMMERCIAL 0 INDUSTRIAL
<br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO
<br /> NEW WATER/SEWER SERVICE NEEDED? ® NO 0 YES,TYPE SIZE
<br /> SITE WORK%RIGHT OF-WAY AP ,1c*T1ON 1NFORMATIKON
<br /> DESCRIPTION OF WORK: .I s l ` a" h I ,h ceiice I 1'1 5brf kMj
<br /> FENCE IN ROW 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 /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT
<br /> 0 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: L� Is a v
<br /> OWNER MAILING ADDRESS: STREET Pi l`{ (0,9117 14-u►.e_. 9(�
<br /> CITY �(,A-P/ STATE ZIP / 0� (
<br /> OWNER PHONE 1{2 5 7,37 6 gl& OWNER EMAIL: I)[t( jettA47 e << • Cat"
<br /> .......�.......MH�.m.,.�.,,�.,�,.�....•.,,�.,�......._w;...,w,.. ...-,�a.V�,.��,....�,..,<...�._w_�_,..,..,w�...�..,.�....M.,�..,.M�..,h.._.,.,..u,M,.,...�: �e�..�,,.� _w�,...�.......,. . ,.,.M..,..,....,...�. ..�..�.......�„�.�_,:.w�.
<br /> APPLICANT NAME: 54 a e
<br /> APPLICANT MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> APPLICANT PHONE: 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.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 /> ke DCI ;6(7
<br /> "PW k910 012
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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