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477 PUBLIC 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 I (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 1611 24th Street, Everett, WA 98201 <br /> IF APPLICABLE: E LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:L7SFR-DETACHED ❑SFR-ATTACHED El DUPLEX ❑MULTI-FAMILY El COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO ❑ YES. FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? Ei NO ❑ YES.TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: Provide TESC,traffic control,rough grading,compaction,and final grading of owner provided backfill material at removed structure <br /> location as required to provide a site free of holes,uneven surfaces,and ponding,Finished grade to align with existing adjacent finished surfaces/grades within the boundary of this work <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING SF <br /> 0 RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> 0 RETAINING WALL/ ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> V CLEARING/GRADING/FILL/EXCAVATE 200 CY <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: City of Everett- Kevin Fagerstrom <br /> OWNER MAILING ADDRESS: STR=ET 3200 Cedar Street <br /> r-„ry Everett TE WA _,F 98201 <br /> OWNER PHONE: 425-257-8565 OWNER EMAIL: KFagerstrom@everettwa.gov <br /> APPLICANT NAME: FORMA Construction Company <br /> APPLICANT MAILING ADDRESS: STREET PO Box 11489 <br /> CITY Olympia STATE WA ZIP 98508 <br /> APPLICANT PHONE: 206-626-0256 APPLICANT EMAIL: LoriN@formacc.com <br /> PRIMARY CONTACT: 0 OWNER ,p APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: 206-475-0792 <br /> Lori Nicholson CONTACT EMAIL: LoriN@formacc corn <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. I am the owner,or t 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 /> � DS <br /> PERMIT�# /^��r'fG .Y!► jiC <br /> -- 01/18/2018 1 V V /3V/ _ 05 <br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016) <br />