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PUBIC WORKS PERMIT AMLICATION <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) everefteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: J OO2 s Zri C i\x\ie 'eV c.re_ 1 W St <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX OMULTI-FAMILY ❑COMMERCIAL ❑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: A- ,(\_)_ ��( ( � aUu Yte fro e <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING SF , <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ' ._.:.,I.) <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> o CLEARING/GRADING/FILL/EXCAVATE CY JUL 1 1 201? <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF CITY OF EVERETT <br /> o CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> Permit Services <br /> CONTACT INFORMATION <br /> l <br /> OWNER NAME: "\Ly .L 4- 1(� \ n <br /> OWNER MAILING ADDRESS: l STREET S-00 2_ S �►�C F}�J�--� ( n` <br /> crrY �( � STATE W tt ZIP CI Ct(2-S <br /> OWNER PHONE: \oO J O OWNER EMAIL: A i V'\ � (O <br /> \AN, — <br /> ,w.. ..Kwm.�...,_..y „ . .�.�.,�,.�.�.M.��... �..�.,w M.. ...�...� ., ri..�...�..... <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑ OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> aCONTACT 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 1 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 /> -7,/ / 11 PW l-7o 4_ 0 /--- <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />