1415 LOMBARD AVE 2020-03-09 - Laserfiche WebLink

PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 OLT (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT SITE INFORMATION: PROJECT ADDRESS: ' 4 : L-6.4NAl+hQ. , 1E__ SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY ❑COMMERCIAL [INDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# UTILITY COMPANY'S NAME&JOB#: JOB# DESCRIPTION OF SITE WORK f RIGHT-OF-WAY WORK FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: ❑ FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: ❑DRIVEWAY APRON/CURB CUT FT WIDE Combined Sewer ❑ASPHALT/CONCRETE PAVING SF 0 Separated Storm Sewer 0,RETAINING WALL/ROCKERY IN RIGHT-OF-WAY L+5 LF 0 Direct Discharge to Snohomish River or Puget Sound ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: 0 CLEARING/GRADING/FILL/EXCAVATE CY P.I MR2 Only 0 MR1-5 ❑MR1-9 ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: 0' SF 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF CONTACT INFORMATION OWNER/APPLICANT NAME: S c cm,ki A OWNER/APP. MAILING ADDRESS: STREET 4 i L.Ov'J3( Ne . CITY r✓ese,„"t' STATE IA 17-4 ZIP 9600 1 OWNER I APP. PHONE: OWNER/APP. EMAIL: *Required for Work in Public Right-of-Way CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): PRIMARY CONTACT: 0 OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: ACKNOWLEDGEMENT..I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must 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 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 perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# 6 'o21.f- / , PW : `70cc,- C ( r Owner/ uthorized Agent Signature Date (Revised 1/72019)