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4/ErrPUBLIC WORKS PERMIT Me PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 3j 0(v 0 L Y.A?e<. - ,c-'ID <br /> SITE WORK FOR PROJECT TYPE: 1 SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX DADU ❑MULTI-FAMILY ❑COMMERCIAL DINDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION=OF:.SITE WORK! RIGHT OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> ❑FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE 0 Combined Sewer <br /> P.ASPHALT/CONCRETE PAVING SF igSeparated Storm Sewer <br /> v <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF 0 Direct Discharge to Snohomish River or Puget Sound <br /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY biMR2 Only 0 MR1-5 0 MR1-9 <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: T SF <br /> 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: Y B 0 SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: 9 8 0 SF <br /> X CONTACT:II+FORMViiitit N:, ,.. :_.. ` . <br /> OWNER/APPLICANT NAME:)//// )Vl>'�1:1CSC,1/71/j4 <br /> OWNER/APP. MAILING ADDRESS: STREET•( / (-36 � y/�� (J S./ �� <br /> /9/C- -4),477---- <br /> CITY I/�/ /// `/, STATE .. 0� e <br /> 11 <br /> OWNER/APP PHONE /O r - <br /> �` WNER/APP EMA <br /> *Required for Work in Public Right-of-Way / , <br /> CONTRACTOR NAME: C�/�i��j� Ai/ <br /> CONTRACTOR ADDRESS: / STREET , y � 1[ <br /> CITY _ZJ STATE 14/,..N,/ zIF��'�Y�^� <br /> CONTRACTOR PHONE. , . er <br /> ONTRACTOR EMAIL: U <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> \N T NAM CONTACT PHONE: .i�' i r_ <br /> .4 . 0i4 =--v�5'c 7/1 CONTACT EMAIL: <br /> •CKA,OWLEDGEMENT::I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must <br /> ply 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 /> f / PERMIT# <br /> ..."0.-;-'. ���=i"�-ww1r .r� • n PW i (�(p- 62(o <br /> ner • horized •.ent •.ature Date (Revised 1/72019) <br />