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PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 'A►/ 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E)evereettteps@everettwa.gov I https://everettwa.gov/permits <br /> ,.k` 3 R* ,EVfts l R;OI:SMA 0140 ;`E11tL MM' '�,'�"''�S, A .a4'a. <br /> PROJECT ADDRESS: g.Od{t�(,43 AVeAlAR,, ak g.Vtrrot - E Vere 4-4-1 WA q g 20 t <br /> SITE WORK FOR PROJECT TYPE:✓✓❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ,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 /> rii7 ". ,.u€ a 7,lY% . :. x - v z y` ` 1.a. 1 +' ,11 fi"; a `.` ,g' 1 rvx �.. N <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 SF4 _ <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF L„eiA1 <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HE1(1 <br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY DEC 0 7 2018 <br /> Nit CUT/BORE IN PAVEMENT(PARALLEL) do LF CITY O F EVERETT <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Permit Services <br /> o POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> 500W S 6( norwiitol.1 6(4p3kr 0.;- t0 -G-F ato PrlNe4. 4evuib t o <br /> Rai l wa Avie.. No ► , ?LAI- 12-I'n,c t 6.ra.4-er 11"&t. Sof-I'tc L s+e--w, l i.�►e <br /> I. . <br /> OWNER/APPLICANT NAME: 14 Group, Inc. <br /> OWNER/APP. MAILING ADDRESS: STREETDo <br /> o <br /> CITY TOLGUMIX. STATE WA ZIP"4$1'18 <br /> OWNER/APP.PHONE: (25 3) 534 qN OU OWNER/APP EMAIL I'_BU Rat 0 MI 4 It I G Rot)P eot( <br /> CONTRACTOR NAME: Not} SerVCces'l <br /> CONTRACTOR ADDRESS: STREET 10621 Todd R., E WA Q 2 <br /> CITY Edt e w d STATE ZIP -t$y4-Z <br /> CONTRACTOR PHONE: (25 3) 601i - I't84$ CONTRACTOR EMAIL:SUPPORT@tjOXSE RVIC-ESINC-.COM <br /> CONTRACTOR LICENSE#(REQUIRED): HOLTSSIMST6 JEVERETr BUSINESS LICENSE#(REQUIRED): 52'16 3 <br /> PRIMARY CONTACT: ,OWNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect,Engineer,Etc.) <br /> CONTACT NAME:Lala.reh ztAfort CONTACT PHONE: (360) 631 -$t•16 c <br /> CONTACT EMAIL:L6VRGH @ M((A M(( R01.)P. COM <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 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 /> 1211-1 s PW I &° <br /> Owner/Authorized Agent Signature Date (Revised 1/52017) ,/t„� r c �1 <br /> 2/f/' +0 OY> p JtAie <br />