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PLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 4rk-77- (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits <br /> ' <br /> PROJECT SITE I. storm iTION.. . <br /> PROJECT ADDRESS: C/10 7 c 4e 4 %„moi-79 �" 7 9Fz x 3 <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE EDUPLEX ❑ADU EMULTI-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 /> DESCRIPTIONOF SITE WORK I RIGHT-00-WAY WORK4` <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> 0-FENCE IN ROW /Z FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE ❑Combined Sewer <br /> 0 ASPHALT/CONCRETE PAVING 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 /> 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 /> ❑POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> o t Y , `o` er <br /> OWNER/APPLICANT NAME: aji tizsi/ 6c c.,E2i,% // <br /> OWNER/APP. MAILING ADDRESS: STREET q/�7 (l�u c,' �✓ 4 <br /> C <br /> 7 CITY / (/GYl/ �! <br /> t STATE l ZIP 9??o/ <br /> OWNER/APP. PHONE: i'1,2:,..1Z d (/Z 70 'OWNER/APP. EMAIL: <br /> *Required for Work in Public Right-of-Way _ ,,, �w A m,,,, <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: 0 OWNER /APPLICANT 0 CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <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.I am the owner,or I am authorized by the owner of thisproperty to <br /> perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WA C. <br /> City of Everett Official Use Only <br /> Ir/AuthIt / PERMIT# <br /> PW 1goy - 05D <br /> V7(V/Y <br /> Ow orized Agent Signature „, Da <br /> (Revised 1/72019) <br />