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PLIIULIC WORKS PERMIT LI ,ATION
<br /> Imo►' 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: 3 1 3 - '!p ! • I,.1 �k:T T a. A lO /
<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 ❑INDUSTRIAL
<br /> CHANGE OF USE? 0[V0 0 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:
<br /> IFENCE IN ROW Y(21 " 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/GRADING/FILL/EXCAVATE CY
<br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF
<br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF
<br /> CONTACT INFORMATION _
<br /> OWNER NAME: d4 /B'S 4574-7E-e-. l
<br /> OWNER MAILING ADDRESS: STREET ,. 10 'O�'/Y► C)� • +°� ,fir
<br /> cry // 77- STATE 4/�jA ZIP I>eJ0 v}
<br /> OWNER PHONE: 6 '� O S~ 6o f 6i 0- OWNER EMAIL: ccc..,,,4 5 G a/-�e e-s 7 Q 4- /
<br /> .».,»M,».AWWIA.........x,, »», .,MMw,,,,*I.IM..M.M»...m,eM1m—, ,,,w»,w. ,. ...M...,.,.,,.».. .»,, »..M„ ., „M.,,.»» .. ,..,.,wMW .», ..,m »...M..„ v,»,.
<br /> APPLICANT NAME:
<br /> APPLICANT MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> APPLICANT PHONE: APPLICANT EMAIL:
<br /> PRIMARY CONTACT: OWNER ❑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 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 /> (",""? --
<br /> ) / ?/P •/./7--
<br /> PW Iia —°°
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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