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FBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 ((E)everetteps@everettwa.gov 1 https://everettwa.gov/permits <br /> PROJECT`SITE INFORMATION ; �. <br /> PROJECT ADDRESS: `e ( % A (,tJ <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODUPLEX ❑MULTI-FAMILY IaCOMMERCIAL ❑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 Z RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: <br /> ❑FENCE IN ROW FT IN HEIGHT <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING SF (} EP <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF p <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT—�� NOV 2 9 2018 <br /> o CLEARING/GRADING/FILL/EXCAVATE CY <br /> CITY OF <br /> EVERETT <br /> L /CUT/BORE IN PAVEMENT(PARALLEL) ( LF Permit Services <br /> LJ- UT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> ❑POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED):DI L ye A tL <br /> lJ <br /> At* cv\v;�,ArsA e.A1p1�\ ID 0C-4, 61•101:4s,,/ ( ' L ('./ RiL& .Trn1e ADCC<<1 s i�t cx`0. (a•t 4x. <br /> b�,(U,A3 (D aka at 2Sa( DC000(Wc� so C�/tic'4 , 1 nC beliA3, akd 1I` otte+1$ I^^� <br /> tow J off' ZSs4- •et gov:tAS ,.4;1l bt ()mirk(' 00(.4 cor,f A <br /> /' CONTACT INFORMATION/ <br /> OWNER/APPLICANT NAME: 6cAv'kt ke. S /CaMt TtJestw ee'- C,. TA(• <br /> OWNER/APP. MAILING ADDRESS: STREET 1 8 tsX is-81 <br /> CITY ( de(I r,cj t.. ` STATE O ZIP 8413 <br /> OWNER/APP.PHONE: eile-70$" CM‘ 'OWNER/APP.EMAIL: GA`�Cbo eS . c6,M <br /> CONTRACTOR NAME: Vre.00kwc.w \ Ase oaks Tv1C • <br /> CONTRACTOR ADDRESS: STREET ('3 g ((Z-.4" avc Ne , 30it. 3(1O <br /> CITY {I' ))we STATE (,t)A zip TsGoi <br /> CONTRACTOR PHONE: 147-S 'CONTRACTOR CONTRACTOR EMAIL: '14\4 <br /> �ehv�rt�a�rtitrl.�a�ctSscsci.adtS�+ic,c 6nn <br /> CONTRACTOR LICENSE#(REQUIRED):t, 811, 1Z9-00 EVERETT BUSINESS LICENSE#(REQUIRED):4""lac+tsc. <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT ' ONTRACTOR 0 OTHER(Architect, Engineer,Etc.) <br /> CONTACT`NAME: CONTACT PHONE: t-(ac -s--10t-S- <br /> CC- <br /> b2S <br /> C. C- (. Z k,c.t CONTACT EMAIL: ZIl,_cap GAVi1.00,AeAkkots5640'HC6 JIL• �o�.. <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 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 /> (/(/‘ /(* Ze( ig PW 1 g f/- CC, 5—g <br /> Owner/• orized Agent Si ature Date (Revised 1/52017) <br />