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14413LIC WORKS PERMIT MLICATION <br /> :4 CITY OF EVERETT PERMIT SERVICES <br /> "111 <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT:SITE INFORMATION <br /> PROJECT ADDRESS: L{ ( 0 roc-c( ../ <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY EICOMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK I RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: <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 /> ❑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 /> ❑POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> 2. 41-42=�ec� <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: 4-,efN� t't) - riy{( <br /> OWNER/APP. MAILING ADDRESS: STREET ej(- (CD+ r6 <br /> CITY STATE Ck--TA <br /> ZIP cnL� <br /> OWNER/APP.PHONE: OWNER/APP.EMAIL: <br /> CONTRACTOR NAME: G-9�cA.r;p Le.> <br /> CIA-CONTRACTOR CONTRACTOR ADDRESS:(,V1S`"L� STREET I• tJ U L�� �/J, <br /> 4 CITY STATE ��o/ ZIP gaog <br /> CONTRACTOR PHONE: 2-,9L2 7Y10 d V g CONTRACTOR EMAIL: /'7:V.e ',9 q 2r1f - cc)-7-44 <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT C CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: ` CONTACT PHONE: 2-0 C . '7 et:, 6.-/0 $ <br /> /l�e l 3 C'1 L,--cCONTACT EMAIL: //4//Ce GQ' 4 £ ��` � , 4jvvk <br /> ACKNOWLEDGEMENT.I have reviewed this application and confirm the information contained herein is true and correct. WorR'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 lam 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 /> 77/e& 9/1 e PW \,(609\ 62� <br /> Owner/Authorized Agent Signature Date (Revised 1/52017) <br />