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IthtibLIC 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 I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 19'31i;'.0 d<E1:1--FJ,I ' <br /> Eit <br /> SITE WORK FOR PROJECT TYPE: ESFR-DETACHED OTOWNHOUSE ODUPLEX OADU 0MULTI-FAMILY OCOMMERCIAL DINDUSTRIAL <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! RIGHT-C#-WAY WORK <br /> . ._ • . . . <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> 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 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 /> 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> ,-. <br /> -€41,2z k rtc/If -of- tuttj-_ <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: vj_jk--i'l.n,k--,' '3} <br /> OWNER/APP. MAILING ADDRESS: STREET / 2.,6,0 t ' 4/ 251----- <br /> ..• <br /> CITY --ire i, .e --/---4-- STATE 111/_777-,/ <br /> ZIP 9Y26;6 <br /> OWNER/APP. PHONE:tf'-' (7)--- !.., )-f.( OWNER/APP. EMAIL: <br /> *Required for Work in Public Right-of-Way <br /> CONTRACTOR NAME: -.'>-e 1 c' <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 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: / CONTACT PHONE: <br /> 1 4 L I- j\--1 , 1,i '') - ./1: i - <br /> CONTACT EMAIL: <br /> KNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must <br /> mply with current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be r <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 /> • Q-1 1'1_ .C..— .,1---S-- / 1 '7 <br /> PW t PiOti—Oi-C <br /> O'rer/Authorized Agent Signature .-- <br /> Date (Revised 1/72019) <br /> i / <br />