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PL LIc WORKS PERMIT ALPLICATION <br /> "tray---4 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©everettwagov www.everettwa.gov/permits <br /> ` I <br /> PROJECT SITE INFORMATION <br /> __. ,. . ... en .._. ..:-. .,` `..}__ - im.. <br /> PROJECT ADDRESS: Aloe �`�/ / 4i) 77 r ?ROD/ <br /> '/ IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX MULTI-FAMILY DCOMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO ❑YES, FROM TO <br /> NEW WATER!SEWER SERVICE NEEDED? 1 NO 0 YES,TYPE SIZE <br /> . <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: /'G/fC irJ5774-6 /C C.6 LOC$ <br /> A-r ,274 d r1I i Q F p <br /> E'ENCE IN ROW 42 oa. L Ess « MF+Tc.N r E-tcaHaort 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: )loRy ( -egNELL <br /> OWNER MAILING ADDRESS: STREET -2_0(-) 2--k)11- , f e. <br /> CITY <br /> y / T STATE WA- ZIP ?ail 2— <br /> OWNER PHONE: Z©Ca _ Js `� ) 70 OWNER EMAIL. ¶E.LL '4 N IO m .;....,.._ `7 •.i/4 V......... <br /> ....M.F... ....,,.m..�w,.w., .n.. ,.M., . ��.��......�p .r._�,.. • m_ , <br /> p ®' t� � C-4YYI <br /> APPLICANT NAME: b A V/2) Ku <br /> APPLICANT MAILING ADDRESS: STREET Po 8.0>c q 14-q( <br /> CITY S '" � . STATE 10(.1/4-- ZIP 76/0-,' <br /> APPLICANT PHONE: SO6 14--5-61'Z APPLICANT EMAIL D.--ifESC_ /TZ Ei�?il�/c_ CQ,1'l EV LLf <br /> PRIMARY CONTACT: 0 OWNER gAPPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME; CONTACT PHONE: C, !{ S!✓j'Z <br /> b4V f/.1 SC-0k)IT CONTACT CONTACT EMAIL: b °7�f-F. N /7 Zaft ► '14-/L • COr1-7 <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 Bu'.mg official before being authorized under any circumstance.I am the owner,or l am authorized by the owner of this property to <br /> pe•orm the work for which ap,,icatio 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 /> Ow 37t'thorized gent Signature <br /> Date (Revised 10/12/2015) <br />