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CLIC WORKS ® Erk MIT PLICATION <br /> ON <br /> •44• CITY OF EVERETT PERMIT SLI li'ICES <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 /> PROJECT ADDRESS: 3 00 Ut) - C4 S 61 Rd. wan -1 S1/ <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) -CPA- /6 'O( <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED 0 DUPLEX ❑MULTI-FAMILY DCOMMERCIAL INDUSTRIAL <br /> CHANGE OF USE? ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK I RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: 2.04 53 x [ C&V1O pia S i ruci rc O iJ e►' COriC rt-ic. s (4 <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> .0 ASPHALT/CONCRETE PAVING / � SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> O RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> O CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: 1a Vi 7 . II jiffy z)ci 2l 6, <br /> OWNER MAILING ADDRESS: STREET 4). ./� -Lt /. DC7 } /''I�s G H- 13 <br /> CITY Sea tti b/A STATE ZIP ��(V y <br /> (� I )) JJ <br /> L 4 <br /> OWNER PHONE: L(25 `�'�li OWNER EMAIL dGcU(�Q.4 � $' I C.(l <br /> APPLICANT NAME: S CO/I d <br /> APPLICANT MAILING ADDRESS: STREET jdh� <br /> CIN STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: 0 OWNER 0 APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <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 1 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 /> kTC <br /> /1*?--/ii; PW1 OA- <br /> Owner/Authorized Agent Sign. re Date (Revised 10/12/2015) <br />