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PUBLIC WORKS PERMIT APPLICATION <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 I www.everettwa.gov/permits <br /> 2 PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: EVERGREEN WAY, EVERETT,WA 98203 <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACH ED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY Vi COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY'APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: NEW CONSTRUCTION OF MIXED RETAIL AND COMMERCIAL SPACE. <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> 0 RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> V CLEARING/GRADING/FILL/EXCAVATE 1638 CY(NET 150 CY FILL) CY <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT=INFORMATION <br /> OWNER NAME: Madison Real Property LLC <br /> OWNER MAILING ADDRESS: STREET PO Box 31609 <br /> crry SEATTLE STATE WA ZIP 98103 <br /> OWNER PHONE: (206) 619-5555 OWNER EMAIL: toddmadison@hotmail.com <br /> APPLICANT NAME: Todd Madison <br /> APPLICANT MAILING ADDRESS: STREET PO Box 31609 <br /> up( SEATTLE STATE WA ZIP 98103 <br /> APPLICANT PHONE: (206)619-5555 APPLICANT EMAIL: toddmadison@hotmail.com <br /> PRIMARY CONTACT: 0 OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: (206)619-5555 <br /> Todd Madison CONTACT EMAIL: toddmadison@hotmail.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.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 I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> % .. oRzi <br /> _ <br /> Owner/Au'ori • Agent Signature late (Revised 9/23/2016) <br />