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OLTPUBLIC WORKS PERMIT APPLICATION <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: 3 4Q 9 Lo..4•6.42.P A,4 c: <br /> SITE WORK FOR PROJECT TYPE: k7SFR-DETACHED ETOWNHOUSE ❑DUPLEX DADU ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <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 f RIGHT OF-WAY'WOkK <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 'Combined Sewer <br /> ASPHALT/CONCRETE PAVING x C7c' . 3 bp( SF' 0 Separated Storm Sewer <br /> 0 RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF 0 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 0.MR2 Only 0 MR1-5 0 MRI-9 <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: P SF <br /> 0 POLEhIVORK/:AERIAL/OVERLASH , LF Proposed Hardscape: 36,0 SF <br /> ADDITIO AL DESCRIPTION(AS NEEDS ^T\ Total New+Replaced: 3 0 SF <br /> I I ) <br /> P `I -�r 2w CONTACT INFORMATION...... . , <br /> -- OWNER/APPLICANT NAME: Gle,.. (,,. (10111 <br /> OWNER/APP. MAILING ADDRESS: , STREET 3 4(›A L o*.+ahc+..o ANA_ U Ie."-;r:--- <br /> cm( -6-VtE(La':— STATE\NA' ZIP GC*i <br /> OWNER/APP.PHONE: OWNER/APP.EMAIL: <br /> . <br /> *Required for Work in Public Right-of-Way <br /> • Ju,rLY <br /> CONTRACTOR NAME: (/‘./. Ziej. <br /> CONTRACTOR ADDRESS: STREET 17_06 ik,, c).<:,or\ ?,_/-14/___7)(_ y <br /> CITY A4, \' (/toA /I/STATE W� I ZIP � SC.73 <br /> CONTRACTOR PHONE: 36-- � f,� —Z��j i( CONTRACTOR EMAIL: re,,,,Q,Jc2r�Xa-.eiL@ �{�I/tv0- ( CP/1'V <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> m... _ ._. . ._ ,. .... _._.- . _ Qom.. — <br /> . PRIMARY CONTACT: 0 OWNER /APPLICANT 'EICONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: ,, CONTACT PHONE:(36?' ) G .- Z s6 <br /> _:),7/CJ`G', tL.e-'c. . CONTACT EMAIL: reej , .,\\vc&L- 0,z....6.-) r,i9. CCM <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is fPue and correct. Work don ursuant 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,',1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> • pW 1geS 05-D <br /> Own Authorized Agent Signature Date (Revised 1/72019) <br />