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FIUBLIC WORKS PERMIT APPLIcATIoN <br /> CITY OF EVERETT PERMIT SERVICES <br /> *44a13200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa_gov https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 5( 3 LELAND 0f( V&ii' INA l S 2.03 <br /> SITE WORK FOR PROJECT TYPE:XSFR-DETACHED ❑SFR-ATTACHED ID DUPLEX DMULTI-FAMILY ['COMMERCIAL ['INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS,ETC.) <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: <br /> D FENCE IN ROW FT IN HEIGHT <br /> XDRIVEWAY APRON/CURB CUT / 5. FT WIDE 301.LONGS' SI Mud ALK <br /> X.ASPHALTRETE PAVING PAX?--p V )3A7 5x2.4. SF 32A--56Z.PT <br /> D 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 M fl <br /> r <br /> Dt <br /> D CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> D CUT/BORE IN PAVEMENT(NON-PARALLEL) LF , L1q i 2 6 2018 <br /> D POLE WORK!AERIAL/OVERLASH LF <br /> CITY <br /> EVERETT <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> Permit <br /> ft✓ +; �': <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: V A\Y W 1 �� <br /> OWNER/APP. MAILING ADDRESS: STREET //5/ L&tA#D]) Pik. - <br /> �Q <br /> CnY Y E1 tG STATE Via ZIP i V 263 <br /> OWNER/APP.PHONE:4,�j�-Tr-7785 OWNER/APP.EMAIL: ..TERk I( 7 14Yf1A//_..-COM <br /> CONTRACTOR NAME: ` <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: OWNER /APPLICANT 0 CONTRACTOR 0 OTHERac)0 <br /> (Architect,Engineer,Etc.)CONTACT NAME: /� �� A Y CONTACT PHONE: 7Gj�. - 7785 <br /> eV 9V V CK CONTACT EMAIL: ,z,Rw'�f J((�t) wOTM 1 L.e (Om <br /> ACKNOWLEDGEMENT:I hive reviewed this application and confirm the information contained herein`"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.lam the owner,or lam 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 /> . AA- L( ,� --/o -is--/g <br /> -�I�Owner/Authori Age Signature Date (Revised 1/52017) <br />