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"IIP''441:•- --":‘ <br /> PUILIC WORKS PERMIT LI AT'ION <br /> _--- CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov l www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 4 q9 7 e fl.e10.1` AU c. i:ver'n-- <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ,MULTI-FAMILY ❑COMMERCIAL El INDUSTRIAL <br /> CHANGE OF USE? T 'NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ,KNO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT OF=WAYAPPLICATION INFORIVIATI,ON „ <br /> DESCRIPTION OF WORK: lip Cctr & ((e» re-f.• Giait - 3)-2- ff. +t C C <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 qDpYox 15- 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 /> x OWNER NAME: i �/`e,nAi 0Vt-05 <br /> OWNER MAILING ADDRESS: f STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> y APPLICANT NAME: , es '(`',d C C\A c� <br /> (1 Ci J. 5 e (i"r 3 <br /> APPLICANT MAILING ADDRESS: STREET C' <br /> CITY STATE ZIP <br /> X APPLICANT PHONE:--(271.-LteJ 5 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 ROW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> --ii7/ G/ (7 PW //0 - O <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />