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4477. PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION', <br /> PROJECT ADDRESS: q GSL)e "e/ .'e 7f tN <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY EI'QOMMERCIAL DINDUSTRIAL <br /> IF APPLICABLE: ❑ 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 F RIGHT OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> 0 FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE 0 Combined Sewer <br /> 0 ASPHALT/CONCRETE PAVING SF 0 Separated Storm Sewer <br /> 0 RETAINING WALL/ROCKERY IN RIGHT-OF-WAY 120 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 0 MR2 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: SF <br /> 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> . <br /> -Cc, f k S ,..` � -c ,1 LU G� W `i\lam. <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: J l I De-'S -/ ✓' L1 <br /> OWNER/APP. MAILING ADDRESS: STREET /<2 j. 2±' Sfi c /� l3 G '/ <br /> e✓L.`F"_ CITY STATE COQ'C- ZIP - 5/ D I -• <br /> OWNER/APP. PHONE: Jk2 G —(. 2/ —LO Z 3—2 OWNER/APP EMAIL: 4.4 I,I J i v1C_ tc� <br /> *Required for Work in Public Right-of-Way <br /> CONTRACTOR NAME: O/l.0 <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: Cj/4 c/V( 9A-4k-cc—// CONTRACTOR EMAIL: .01001 l ris O <br /> CONTRACTOR LICENSE#(REQUIRED) JT /L/3E l > l/()Lk LICENSE#(REQUIREb)11° rQ 06 <br /> EVERETT BUSINESSr <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT gi-V5171TRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: <br /> CONTACT PHONE: ,-13/,,C) -(rj 2 ( —&,2.3 <br /> t CONTACT EMAIL: dtt.t,L02_,t1 L.IL C-$ a ✓ice c'O y�� <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.lam 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 /> /13/1 PW J ., _ r <br /> Owner/Authorized Agent Signature Date (Revised 1/72019) <br />