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PLIPLIC WORKS PERMIT ATIPLICATION <br /> .4 CITY OF EVERETT PERMIT S=RVICES <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 /> PROJECT SITE INFORMATION <br /> 12 <br /> PROJECT ADDRESS: 2 -7 7C �0 y ,4 vey E 'EX-E-i/, k//9 ✓g 2-2- <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED 0 DUPLEX 0 MULTI-FAMILY ZCOMMERCIAL El INDUSTRIAL <br /> CHANGE OF USE? x NO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? X NO 0 YES,TYPE SIZE <br /> SITE WORK/RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: ie�j /ASG a A 4i ti u. e,e /Z/�e . /ea ie a• <br /> r€6 e2Ze z/ Y'Wiv . Z /:iv ''i ray //�Le pe-oroe ry <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING ,/67 V 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: def.)-5 TAO eQS%<3i3,y ,J6-' ( L7S"7,9/ <br /> OWNER MAILING ADDRESS: sTREEr 4/130 12 2 p/ 3 e �' a <br /> CITY E 1/E-46-I 6- J j7 STATE (4-/ft G�2`ZIP ✓ Oc <br /> OWNER PHONE 1/25 — 73 7 UP OWNER EMAIL. C1/1"39 0...C.---i7 -7,e7 ''.2.‘.„)� c.Z. 04, -)-..... <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: x OWNER ❑APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: //26 — 7-3 7 - C)&7 S <br /> 40s f CONTACT EMAIL: / ,�iJ O,c--C j�( ���j '. et it7 <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant t 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 /> , C)� �, 03 22 -1 PW <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />