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PaILIC WORKS PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 4111, 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits
<br /> . .; PROJECT.SIT�E�INFORMATION
<br /> PROJECT ADDRESS: (O lr�f I ��."�, .., e:, It 2 12.„k\)C.:-1 ' ....i/L: L1 - }� 2...O`
<br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DDUUPPLEX DMULTI-FAMILY A'COMME CIAL DIN USTRIAL
<br /> �
<br /> IF APPLICABLE: XAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) -C (.4" ��`2... ___ �^ ai,t)
<br /> IF APPLICABLE: 0 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: C'r
<br /> ❑FENCE IN ROW FT IN HEIGHT � la .06
<br /> /thilf/& *•496.5
<br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE OW
<br /> ❑ASPHALT/CONCRETE PAVING SF W�/, /9/441 /e4 j) r�
<br /> Pt()
<br /> I�"
<br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF & in-Sped/7371
<br /> &t2
<br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT (,
<br /> X CLEARING/GRADING/FILL/EXCAVATE t(?)/. 00C-) CY
<br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF
<br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF
<br /> ❑POLE WORK/AERIAL/OVERLASH LF , t
<br /> ADDITIONAL DESCRIPTION(AS NEEDED): C,kc'C) Y'� C) , (?)e,,.„10(7) C�� j ( ,*r-=_ c t ret._
<br /> 4.,.--,-cbc_;t4.--.\t
<br /> . -o*- \ S11'e . (- 'c (..- Vly •fO-€d OE-l/\R. 't...'LSi 2 ,
<br /> ',.t,lit -Q_.-€.--T i.% .j, .,A.. ..- 'r.j .. ; --0-o'Ni ` 0 i i-ci. tt ., U jc 0-c,N `CJ Y
<br /> -1 V e . (Pe+-mi4-- r .t in 0-F moist-(2 &ibri cbd -C (Ink p petrol , 1/4400
<br /> CONTACT INFORMATION --.�." ,
<br /> OWNER/APPLICANT NAME: () ?_`f �_L5'i2.1(..,C.. 71.-- I`.)\ s'"T-' Mi L`< ,, L: (._ 4 C,OWNER/APP. MAILING ADDRESS: STREET P•1L 0 ek-Litii'c.(.�.VIL C \ ej°
<br /> r 4I �" I
<br /> CITY 4- c4
<br /> H:7:.J CA40is's1 ke514 STATE A- ZIP ; 0.
<br /> OWNER/APP.PHONE 42-c- ` , 01 OWNER/APP EMAIL C, g J i14.e.., 11/4-\. CO
<br /> CONTRACTOR NAME: a:g.,
<br /> ,-,-..- ,_. ,,,,,- ,,..
<br /> ,I z.,,t,,,. ; :, , ., t,4, ;,,,,,,----'\
<br /> CONTRACTOR ADDRESS: STREET 141 S s av1
<br /> ,.d
<br /> COY ji ) , STAT Is 1 n I
<br /> l P
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> t
<br /> CONTRACTOR LICENSE#(REQUIRED) EVERETT BUS FASL NNS f
<br /> PRIMARY CONTACT: 0 OWNER /APPLICANT 0 CONTRACTOR OTHER Architect, ngineer, c`}:c-Z: i ~ .k}i -e12't,
<br /> 44CONTACT NAME: t, CONTACT PHONE: +2„.S-'. g,,'z_ •7 i .
<br /> 72(4"i ✓Z-4- i t ".� (141-)A. CONTACT EMAIL: N'►4 4(-0;215‘,L,• - K IK` xLP 1r r(
<br /> A KNOWLEDGEMENT::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 /> APA
<br /> PERMIT#
<br /> 11L` ,' PW \ o32
<br /> Owner/A 4 ¢ed Agent Signature Date (Revised 1/52017)
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