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4rErrPUBLIC 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 -.,�. S r V 7 <br /> ADDRESS: J ` " 3 Z {/T d L-,-5 G <br /> JJ v,(i(/`C-f 11' 7 C,i 2c) <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY ❑COMMERCIAL EINDUSTRIAL <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 I RICHT t =1N IlY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> p FENCE IN ROW �% c < -- FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE 0 Combined Sewer <br /> ❑ASPHALT/CONCRETE PAVING SF 0 Separated Storm Sewer <br /> ❑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 /> 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 /> ❑POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> ` CONTACT��NFORMATIQN <br /> -- OWNER/APPLICANT NAME: R 9 L c,J--Sj LL C <br /> OWNER/APP. MAILING ADDRESS: STREET [-0 ) [ C S <br /> CITY 1rr 1 \ , STATE LJ (//1- ZIP ggGJ <br /> OWNER/APP.PHONE: (OWNER/APP.EMAIL: __ <br /> *Required <br /> Re wired for Workin Public Right-of-Way .....q r n <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> —�►PRIMARY CONTACT: DOWNER /APPLICANT 0 CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: L- S b ' <br /> 4,( CONTACT EMAIL: QCt / ( �7r1 eQ c - LCA <br /> ACKNOWLEDGEMENT.I have reviewed this application and confirm the information contained herein is true and correct. ork 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 t e w rk 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 /> /i3 /1 PW 96 4 - c)3 <br /> Owner/Authorized Agent Signature Date (Revised 1/72019) <br />