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NBLIC WORKS PERMIT SPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https:Heverettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: &reffl MIA O 0 <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX []MULTI -FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br />IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # <br />UTILITY COMPANY'S NAME & JOB #: JOB # <br />DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <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 SF <br />TAINING WALL / ROCKERY IN RIGHT-OF-WAY a�' I31% LF <br />*RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />s <br />❑ CLEARING / GRADING / FILL / EXCAVATE CY <br />❑ CUT/BORE IN PAVEMENT (PARALLEL) LF _ <br />am? <br />❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF g L jAP <br />❑ POLE WORK / AERIAL / OVERLASH LF 1 ; <br />ADDITIONAL DESCRIPTION (AS NEEDED): d�' �$ <br />EVERETT <br />CONTACT INFORMATION <br />OWNER / APPLICANT NAME: e g... <br />OWNER / APP. MAILING ADDRESS: STREET <br />' CITY <br />STATE ZIP <br />OWNER / APP. PHONE: P -� �' J %J <br />WNER /APP. EMAIL: �„t{�(,� P P Ga <br />pp <br />f, cA 0 Vef" 40 rS. <br />CONTRACTOR NAME: bj At Land ji'm �VI �7 0 K7 <br />e� a [ p� J <br />CONTRACTOR ADDRESS: / Z'7 • <br />j <br />CONTRACTOR PHONE: "4ZS-3:55— <br />CONTRAC OR EMAIL: ►�'1a��QIhG(S y►1 N C,0M <br />CONTRACTOR LICENSE #(REQUIRED): <br />EVERETT BUSINESS LICENSE #(.REQUIRED): <br />PRIMARY CONTACT: j<OWNER / APPLICANT ❑ CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: <br />CONTACT PHONE: 4 — ,6Z —1 /30 <br />CONTACT EMAIL: <br />t24 12 e co <br />ACKNOWLEDGEMENT.. I have reviewed this application and confirm the information contained herein is true and Mrrect. Work done pursuant to th%-termit 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 fheytilding 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 p- lication 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 />A PERMIT # <br />�Z4 /-Zff-/7 I PWW 11© ( -- 00-z- <br />Owner/Authorized Agent Signature Date (Revised 1152017) <br />71 <br />