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PLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 J FAX 425-257-8857 J (E)everetteps@everettwa.gov f www.everettwa.gov/permits <br /> • PROJECT SITE INFORMATION • <br /> PROJECT ADDRESS: 59 Do 64,-INA Ave u63. S RET IAA S 2a <br /> IF APPLICABLE: IJ LAND USE PROJECT#(SEPA,PRE-APP,SS,ETC.) NSI <br /> SITE WORK FOR PROJECT TYPE:OSFR-DETACHED DSFR ATTACHED °DUPLEX DMULTI-FAMILY COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO 0 YES, FROM TO <br /> — <br /> NEW WATER!SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE lig SIZE <br /> SITE WORK t RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: VACIbR "rIZUCX -E EXtSrtt+C 1Xrtt1Ttes U4 1 t 1 <br /> abJORle.ro -ria 14E' e. , i t tiEc Jr -ror'` Zap o.1-y NON 14l/g U . <br /> ❑FENCE IN ROW FT IN HEIGHT <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING SF <br /> 0 RETAINING WALL I ROCKERY IN RIGHT-OF-WAY IF <br /> 0 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 /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION • <br /> OWNER NAME: Lee(a8, 1,..1.4.0 <br /> OWNER MAILING ADDRESS: STREET }CyD W. 601.04114(11" t4 T.>5.* C€. ep0 <br /> vitce <br /> crry YttNotl•MER.. TSTA ibC+ zip 1/ttt64441.. <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: 't'S RCS CoNis uatXtbII,I 1!„Xa,. <br /> APPLICANT MAILING ADDRESS: STREET(1?o.8oX 1'"66) "I"7' Vtl. soSniemq ROI°►D <br /> CRY y4Oa0INVIL4E STATE VA ZIp %6On. <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: 0 OWNER id APPLICANT 0 OTHER(Architect,Engineer,Etc.) <br /> CONTACT NAME: ./. CONTACT PHONE: (42,3)4 «3y to6 <br /> CONTACT EMAIL: 'o"k'411a5br'acm,.pdty.� <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,ori am authorized by the owner of this property to <br /> perform the work for which application is made,and 1 comply with the State Contractors Law 18.27 RCW and 29&200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> VI/9 011 PW r O Olt+ <br /> Owner/Authorized Agent Signature Date (Revised W23/2018) <br />