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PLIC WORKS PERMIT PLICATION <br /> 11.111d/ <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: q 3 2. 241)E- <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPESFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE?, INO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? Arrib ❑YES,TYPE SIZE <br /> SITE WORK/ RIGHT OF=WAY'AP PLICATION INFORMATION <br /> DESCRIPTION OF WORK: � \A(. l° Gb-f-c a --(nee I <br /> r <br /> i(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 /> CONTACT INFORMATION <br /> OWNER NAME: lek_5 P Ai15U42 / (�Cc <br /> /3e* <br /> OWNER MAILING ADDRESS: STREET - z eLcCA t2 <br /> CITY EVeI` STATE a,* ZIP CJ V-0) <br /> OWNER PHONE: 1-12-&— 2.51 - 'Dlo OWNER EMAIL: a04Ca72CA51-1 <br /> APPLICANT NAME: Ai irSV'1/t <br /> APPLICANT MAILING ADDRESS: STREET ni\-t___, <br /> CITY STATE ZIP <br /> APPLICANT PHONE: ' L lkt.. _ APPLICANT EMAIL: <br /> PRIMARY CONTACT: 'OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: /2.5 )b 3 <br /> O& 1 0{4' CONTACT EMAIL: _/ A) <br /> ACKNOWLEDGEMENT: have reviewed this application and confirm the information containeherein 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 t comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> Owner/Authorized gent Signature Date (Revised 10/12/2015) <br />