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/1411d----.4 <br /> P ILIO WORKS PERMIT 1PLICATION <br /> CITY OF EVERETT PERMIT ICES <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 /> , ..r.. ._ ' ,PROJECT SITE`IN0#14A0.fi . <br /> l . n.-". <br /> PROJECT ADDRESS: O`0$ c J Al v,-.:(4 f (hit ci 10 l <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE APP,SS,-ETC.) <br /> SITE WORK FOR PROJECT TYPESFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ID INDUSTRIAL <br /> CHANGE OF USE? .IZNO ❑I YES, FROM ,A11019TO <br /> NEW WATER/SEWER SERVICE NEEDED? Al NO 0 YES,TYPE SIZE <br /> S:07011 ORK if RIGHT4 OF WAY APPLICATION 31NFORMATT'ION <br /> DESCRIPTION OF WORK: <br /> ❑FENCE IN ROW FT IN HEIGHT <br /> DRIVEWAY APRON/CURB CUT FT WIDE <br /> Vf-ASPHALT/CONCRETE PAVING b5-55 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: 11/49lAM l%C1, AVL <br /> OWNER MAILING ADDRESS: STREET -37 AA <br /> CITY STATE ZIP <br /> OWNERPHONE-.r ---,_— 2..3.M.....g�..,.�2.. . OWNER EMAIL,... .,..,.........--,....,............—,.-....._..,w..,.. .,..,.... ..,...,a.,,e...,..,.,. .M...,--..— ,,,,......wM—.— <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: we� n�, n, vaxe .APPLICANT EMAIL: <br /> m, �ve µye^ A. y.-a .rt own — <br /> PRIMARY CONTACT: )WNER 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 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> / PERMIT# <br /> 0 - �' /� PW/6®1/—®lO <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br /> • t� <br />