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OiSem- IF—3LIC WORKS PERMIT E 'LICATION <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: <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX EADU ciMULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK I 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 /> ❑DRIVEWAY APRON/CURB CUT FT WIDE 0 Combined Sewer <br /> 14 ASPHALT/CONCRETE PAVING e.,3 7 SF Gam'-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 /> 0 CLEARING/GRADING/FILL/EXCAVATE CY Q_MR2 Only 0 MR1-5 0 MR1-9 <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: <br /> SF <br /> 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: /93 C+ SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: S..3`7 SF <br /> CONTACT INFORMATION . <br /> OWNER/APPLICANT NAME: il U IC- S l L\ —AC-ICC LC (- <br /> OWNER/APP. MAILING ADDRESS: STREET J'151) L A2 i✓S PUS (1)11--(- -E-- <br /> CITY Ci4 S2— STATE Cil ZIP J f 3 C, <br /> OWNER/APP. PHONE: OWNER/APP EMAIL: <br /> Required for Work in Public Right-of-Way <br /> CONTRACTOR NAME: ,S jei(,+-177\1 114-_`L--) <br /> CONTRACTOR ADDRESS: STREET '2 NyO est `7 Co T4 �2 <br /> 0 _ S <br /> CITY C„,—.57,7) I,,/'3 v 11 STATE L,\--,, ZIP 62807'2. <br /> CONTRACTOR PHONE: Li Z -- S"(-( - `1 (s,O U CONTRACTOR EMAIL: C. L-tS 7(2,0402 /40 fli14SCU OA vI7OfFkS ,Cc,rt., <br /> CONTRACTOR LICENSE#(REQUIRED): e�f_,.FLt. y ' EVERETT BUSINESS LICENSE <br /> #(REQUIRED): (4 C2-S 2..736 z <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT1 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: i42- Sc.7 I _ Li(oog <br /> C 4-e2A rkt -Ai�' CONTACT EMAIL: K_tS7aPt1R,2 ' 140A/1AS C Vt zia170)C&J. Ce,t-., <br /> ACKNOWLEDGEMENT.'1 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 /> perfo , - work forty icpcation is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> i <br /> City of Everett Official Use Only <br /> ..../- PERMIT# <br /> ,r----------_ PW /q,3-O 6 4- <br /> .• - •u g Age t Signature Date (Revised 1/72019) <br />