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P LIC WORKS PERMIT PlirPLICATION <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: 2521 Lorri t-4 Ave <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:ESFR-DETACHED ❑SFR-ATTACHED 0 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 APPLICATION'INFORMATION <br /> DESCRIPTION OF WORK: S7X4- cv1'btc��l a�►1 `t�it�� <br /> FENCE IN ROW (P FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE P•15. 0'° <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> 0 RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑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: it'll MA.( -( L A:4* U'\ QhuccI <br /> OWNER MAILING ADDRESS: STREET '2.5a I l-om bqr°( /4 q �) <br /> CITY EVQ.�'-e+ STATE POA ZIP ! 6 2 <br /> OWNER PHONE: LIa5--252=7033v OWNER EMAIL: ((CP.o o ttp @ rrict ( - <br /> APPLICANT NAME: 6l-er —atoms. , Lha/r'rno.n <br /> APPLICANT MAILING ADDRESS: STREET 25.7-t 4,Orgt Ord / <br /> CITY . Ver.e.*4 STATE A- ZIP 9 8'2-.O/ <br /> APPLICANT PHONE: 4'23-- 252- -703 ' APPLICANT EMAIL. t(Ce o t'ce 4=r'141, <br /> 7 <br /> ,.w—C <br /> PRIMARY CONTACT: 0 OWNER 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 /> Aokee,y PERMIT# <br /> Y/,//f PW 180'1-O <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />