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pUllkic WORKSPERMIT 1:- LIC TI <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwagov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: q7O l '- r CU <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL DI INDUSTRIAL <br /> CHANGE OF USE? • ❑NO ❑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: (t. (A1{--7 A. • `�fe EF <br /> NCE IN ROW (9 FT IN HEIGHT <br /> ,� iL"` s't i <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE i L ' �e I `4) <br /> ❑ASPHALT/CONCRETE PAVING SFlU I i I <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF t 1 0 2018 °dt <br /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT C ITS Y OF EVERETTEVER <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY Permit <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: d,,,,,,,,, 1IAJO �``2-- <br /> OWNER MAILING ADDRESS: STREET 'Z.09 '-' .(2. 1/\._, <br /> CITY STATE 1,04- ZIP 9.21 <br /> Z 6 <br /> 3 <br /> OWNER PHONE ( ZS- <br /> 7F2 — rZ&' OWNER EMAIL JOAI fin(© . .e.MA-(L•n CO <br /> APPLICANT NAME: d f15p/-i Ctsio 1 _ <br /> APPLICANT MAILING ADDRESS: STREET 7Zo 7 � 6•3 <br /> CITY vE'TT" STATE tA)/4 ZIP ?eie <br /> APPLICANT PHONE 2� 77 12& APPLICANT EMAIL: sj+4.50A!LCksa.co v -('MA ft_ C o <br /> PRIMARY CONTACT: OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: -/Zs 772 ( 2(Q3 <br /> dpeso i .I C1,--I 0-vele-- CONTACT EMAIL: Jr49oAI C-GoA_f.„12 J M-A•I'L . Co-1A& <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 /> PW isos- os co <br /> Ow er/ uthorized Agent Sign(0,.....,..s...-._- <br /> Date (Revised 10/12/2015) <br />