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PUBLIC WORKS PERMIT AI-PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> 4ZETT (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATi - <br /> PROJECT ADDRESS: co l C eW c ( o f 2_3 IcA 17 1,01,1- <br /> SITE <br /> ,01,1SITE WORK FOR PROJECT TYPE: DSFR-DETACHED ❑TOWNHOUSE ❑DUPLEX DADU DMULTI-FAMILY DCOMMERCIAL DINDUSTRIAL <br /> IF APPLICABLE: ❑ 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_.SITEWORK./`RIGHT-OF-WAY.WORK: , - <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 0 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 MRI-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: SF <br /> 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> CONTACT.INFORMATION..... .. <br /> OWNER/APPLICANT NAME: ( . " LA(A_ <br /> OWNER/APP. MAILING ADDRESS: STREET Wil,(o i (-('r Scac"� (CQ v� (k)O�-t,1 <br /> CITY t-�Jr 1� t Lk <br /> .)C_)l JO(J))� STATE l��'/( ZIPq-d0 <br /> OWNER/APP PHONE C\�,' 7 C ((J OWNER/APP EMAIL 525I, 1 pecA q p'1710 1 it C C <br /> *Required for Work in Public Right-of-Way <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: ,OWNER /APPLICANT 0 CONTRACTOR 0 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 this property to <br /> perform the work 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 /> -�� PW I`tb6— 9A <br /> 0vJne horized Agent Signature Date (Revised 1/72019) <br />