Laserfiche WebLink
OW.44,1-`,....a' <br /> IIUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> vilici 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: p2 p?p 1 AlDo,.2.,if at'- <br /> SITE WORK FOR PROJECT TYPE: DSFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX CI MULTI-FAMILY DCOMMERCIAL [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 /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> CLEARING I GRADING/FILL/EXCAVATE to 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: <br /> OWNER/APP. MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER/APP.PHONE: OWNER/APP.EMAIL: <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: •CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): 1 EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer,�/ Etc.) <br /> CONS CT NAME: � CONTACT PHONE: Li, 5- 1�O 3' S fl <br /> ' atv Ake 4( CONTACT EMAIL: 4\/2 r if', 6havY1 61., ifro. ( in <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Worone 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 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 /> 1 t't2- ( PW I81a-03q <br /> Owner/Authorized Agent Signature Date (Revised 1/52017) <br />