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tUBLIC WORKS PERMITTPPLICATION
<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 https://everettwa.gov/permits
<br /> „4..= tr7 •,.AOJECT SI e:E"NFORMATI: ,> SSI .tea': . .wy.
<br /> PROJECT ADDRESS: -- ,3/ 0 HD" f. ,,4/e very ft W Gf 2-03SITE WORK FOR PROJECT TYPE: ❑SFR-'dETACHED EITOWNHOUSE ['DUPLEX EADU EMULTI-FAMILY EICOMMERCIAL ['INDUSTRIAL
<br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.)
<br /> IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT#
<br /> UTILITY COMPANY'S NAME&JOB#: JOB#
<br /> WORK.: • ;tet,.
<br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS:
<br /> ❑FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO:
<br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE VI Combined Sewer
<br /> O ASPHALT/CONCRETE PAVING 3CC; SF ❑Separated Storm Sewer
<br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑ Direct Discharge to Snohomish River or Puget Sound
<br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS:
<br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY 1/MR2 Only ❑MR1-5 El MR1-9
<br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES:
<br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF
<br /> ❑POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: .3CIC' SF
<br /> ADDITIONAL DESCRIPTION(AS NEEDED): 1 , . , ,1 n ) /� l Total New+Replaced):_ ac; SF
<br /> update AtT pct,v1Lt,c to (a 1M./ke V k J A-CC-e`'CI b )e. S ��l-e e
<br /> OWNER/APPLICANT NAME: Prel,(1C(_v-1 Gt,J Recc,I,i,+r-e, -T-e �r� Sn a)C�/i /.sG) roux)
<br /> OWNER/APP. MAILING ADDRESS:: STREET 3i(,l -f- Av e.
<br /> -
<br /> CITY fv ere- \� STATE tv A- ZIP q`J 203
<br /> OWNER/APP. PHONE: rj -- 33ri - v� 7rj !OWNER/APP. EMAIL: Si h&vll e ✓rea..IC huicef C Din
<br /> *Required for Work in Public Right-of-Way
<br /> CONTRACTOR NAME: RQ Nie VIA t✓L"r Mai/v-1'11-5
<br /> llll
<br /> CONTRACTOR ADDRESS: STREET J /g PI uG 1 ee rs /�W • w XJ SppI
<br /> CITY S7ai�. 00! STATE (41A- ZIP`I82 2_
<br /> CONTRACTOR PHONE: a5j 3n 1 CONTRACTOR EMAIL:
<br /> `� � b'c,UAcw11Kijp(1) ewtatifi-Ntw'�+~,n�_S.
<br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED):
<br /> .. ,.,,. .y..,. .na•,r„,” .. ........ ......y.,.,,.aw+•..,,,r:,� ,.,shy.s..eu c. , �aeuz.,, ,...,,,., ,,.,.. �. .......,. . Kttc,�.,..... .....aaw .» �a .woary.,ro.u„ Sy .,,,,,..a .,. ...
<br /> PRIMARY CONTACT: ❑OWNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NAM : CONTACT PHONE: (,+Xc;" - 3-3t' /`7 C-
<br /> n (/k(CJ C t v CONTACT EMAIL: st�')v-, (eta)(�oc�JGC VW IG S,,, ce\ i�
<br /> ACKNOWLEDGEMENT:I have reviewed this appliebtion 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 /> ' d _ PERMIT#
<br /> j(. = - (o 3 - (r'I PW . -
<br /> �,i'OvJlaer/Au o zed Agent Signature _ Date (Revised 1/72019)
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