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PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT ADDRESS: ,3 7 // ( Q, <br /> SITE WORK FOR PROJECT TYPE: BR-DETACHED ['TOWNHOUSE ['DUPLEX ❑ADU ❑MULTI-FAMILY ['COMMERCIAL ['INDUSTRIAL <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> illWeinktRAMWMMITMIMATMITIVrittMt lei\ Th.$.° w.raitni - <br /> EREMINS <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 ❑Combined Sewer <br /> ❑ASPHALT/CONCRETE PAVING SF 0 Separated Storm Sewer <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑Direct Discharge to Snohomish River or Puget Sound <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY ❑MR2 Only ❑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: SF <br /> ❑POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> 4P. ç - v <br /> •` "\4vhw _`� V��,���� .a. .t ..:..S�a�i <br /> OWNER/APPLICANT NAME: L. G - ��/' ��=` <br /> OWNER/APP. MAILING ADDRESS: STREET 37/�/ , '/.. <br /> CITY . -v E STATE W4 ZIP <br /> OWNER/APP.PHONE: 41.2s" 47 2 3yt66- 'OWNER/APP.EMAIL: <br /> *Required for Work in Public Right-of-Way <br /> CONTRACTOR NAME: S- / f/ <br /> CONTRACTOR ADDRESS: STREET 2//�- , l A/,��� /i/J ZIP L <br /> CITY C(�7L/V Y tt STATE V VG�i2C, <br /> CONTRACTOR PHONE: T 21� G (CONTRACTOR EMAIL: ) S�?�^/����T/T ec-1/ACT C <br /> CONTRACTOR LICENSE#(REQUIRED): < N.Eg I EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER /APPLICANT O'CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: `, jE2, c CONTACT PHONE: L-f 2.�j 1 2-3 ' cl SC <br /> CONTACT EMAIL: ;7 �e) ,1a o(& �c-�IJY J e.G1�✓\ <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 /> AI? P R SIT# - <br /> 7)4 \ \A \ b() <br /> Owner/A !zed Agen ignature D to (Revised 4/15/2019) <br />