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See, 01ct-Ce/� A,�CISC� fro cc. <br /> 001/w�� PUBLIC WORKS PERMIT APPLICATION <br /> 011110OF 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 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 21 ° ) EV e, r t 44 <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:DSFR-DETACHED ❑SFR-ATTACHED DDUPLEX MULTI-FAMILY ❑COMMERCIAL DINDUSTRIAL <br /> CHANGE OF USE? I NO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? I9'NO 0 YES,TYPE SIZE <br /> SITE:WORK,/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: Pe_vpark`; 43-02_0.„ <br /> E FENCE IN ROW FT IN HEIGHT <br /> D DRIVEWAY APRON/CURB CUT FT WIDE <br /> D ASPHALT/CONCRETE PAVING SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> D RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> D CLEARING/GRADING/FILL/EXCAVATE CY <br /> D CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> D CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: Ci1r� m 1 „L. e . 6 5'\-G..4 L 5 k4.N...v __ K 4 v` <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: - c Ni 4 G..; \ <br /> APPLICANT MAILING ADDRESS: STREET 51 5 / (�L�i e. <br /> crry W STATE ZIP q g Z7 <br /> APPLICANT PHONE:,92-550% -(p Y 07 APPLICANT EMAIL r 5 ,0YN 50. , irk.o"y'h15,$ <br /> PRIMARY CONTACT: 0 OWNER J APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME:( CONTACT PHONE: Li ZS — C1 J 8_ W y �t'7 <br /> Gy k srJ �„ S r, CONTACT EMAIL: 1j r�l S Aye c� <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 l 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 /> PW /607—Q51. <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />