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,r• - *$ ti } 'fes` <br /> PUBLIC WORKS PERMIT <br /> ATION <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.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: (4602- Z Ste' <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR ATTACHED 0 DUPLEX 0 MULTI-FAMILY ❑COMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK,/ RIGHT-OF WAY APPLICATION'INFORMATION <br /> DESCRIPTION OF WORK: Wit]t 16; //RI , & f1 /22 ( c <br /> o 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 /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> S <br /> OWNER NAME: OO14 W1 IS C-bt.) - i9reu L/O ('5k) ojkhsh 5 <br /> OWNER MAILING ADDRESS: STREET 2 S�l t� 6.1}1-4 F0vC--)0 i. <br /> CITY 2� "�1�--1� STATE W A ZIP `( ZD 1 <br /> OWNER PHONE: C-I�-5-2-3( -1 4'5 OWNER EMAIL: )5YL-0">►S St•Jt7 e't)10 C c Y� <br /> APPLICANT NAME: y"Y ` /4 <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: tg OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: `-1 2�_ Z3( —21 Li 5 <br /> 1.-3 (A) 0 t CONTACT EMAIL: 1 i�_4'J>�a S c <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 lam 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 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PW 1$05-0l0 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />