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PUBLIC WORKS PERMIT APPLICATION <br /> "1EJA <br /> CITY OF EVERETT PERMIT SERVICES <br /> �- 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov https://everettwa.govlpermits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: /60 2- (cd Qa Vey V ef 'j q <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX OMULTI-FAMILY ❑COMMERCIAL DINDUSTRIAL <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 /> ❑FENCE IN ROW FT IN HEIGHT <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE <br /> ASPHALT/CONCRETE PAVING Ashrompowstifieggsycr /,9 99 SF <br /> -4 0 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 /> ❑POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: S-'Ev S 44 Av.; / Ss*A.#.1 '2a tLo 11*-pv,Ih y t.t_C._ <br /> OWNERt APP. MAILING ADDRESS: STREET /p 2,6 / 4 s-r..a A.%)E til F` <br /> CITY t= STATE "i6JA ZIP 9$c.'1 <br /> OWNER/APP.PHONE: OWNER/APP.EMAIL: <br /> CONTRACTOR NAME: g (V\0\ � 6�ccc�U t 2 �, <br /> CONTRACTOR ADDRESS: STREET 1701.o1 e `r�c� ,.})A <br /> ICcktTe44- CITY STATE [ A)`A ZIP ?�ZQ <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: V <br /> CONTRACTOR LICENSE#(REQUIRED): C p k)0 A C.4S.,�s 6 I EVERETT BUSINESS LICENSE#(REQUIRED): .5 9 9 53 <br /> ,PRIMARY CONTACT: ❑OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect,Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: Z c G 3$"L(- -g <br /> ok.VinS o c:,,tfc-z- CONTACT EMAIL: 5Cmmwiag eG(4.c) q'( <<< ( V <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and conlect.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 tam authorized by the owner of this property to <br /> perform the work for wh'ic`h application is made,and!comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> \c'ot\ Gt✓z f�_ �z- zo(re PW / 6 /2 - o32 <br /> Owner/Authorized Aterit Signature Date (Revised 1/52017) t a <br /> • <br />