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"1111 -- <br /> PAILIC WORKS PERMIT PiH3LICATION <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 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION, <br /> PROJECT ADDRESS: 4s09 5trtej <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED 0 DUPLEX 0 MULTI-FAMILY ❑COMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? 0 NO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK I.RIGHT OF-WAY`APPLICATION INFORMATION . <br /> DESCRIPTION OF WORK: /?ic. U gvvA.?( <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> PC-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 /> CONTACT INFORMATION <br /> OWNER NAME: jr� V 1 C_k i to, Perii-'I <br /> OWNER MAILING ADDRESS: STREET Agog ISI I *r- . <br /> CITY av e 1' STATE WAr _(_, ZIP 9 8ro <br /> OWNER PHONE �-DS-?j.1-5-34 OWNER EMAIL: U j Ck l e- lea Y o-fr \ li ' coiy-1 <br /> APPLICANT NAME: <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 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> jijid e - PeA <br /> JJ4) ) <br /> pW / 7C- o6 <br /> Owner/Authorized Agent Signature ( D (Revised 10/12/2015) <br />