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PWLIC WORKS PERMIT MPLICATION <br />CITY OF EVERETT PERMIT SER ICES <br />EVERETT <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: 9 O'2 - /�. 'aIZvaU LZ A t \J e-LZ c—Tr IQ• ct 2-e / <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY SZOMMERCIAL ❑INDUSTRIAL <br />IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # <br />UTILITY COMPANY'S NAME & JOB #: JOB # <br />DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <br />FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />❑ FENCE IN ROW FT IN HEIGHT <br />❑ DRIVEWAY APRON / CURB CUT FT WIDE <br />❑ ASPHALT / CONCRETE PAVING SF <br />❑ RETAINING WALL / ROCKERY IN RIGHT-OF-WAY LF <br />❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />❑ CLEARING / GRADING / FILL / EXCAVATE CY <br />❑ CUT/BORE IN PAVEMENT (PARALLEL) LF <br />❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF <br />❑ POLE WORK / AERIAL / OVERLASH LF <br />ADDITIONAL DESCRIPTION (AS NEEDED): <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO: <br />❑ Combined Sewer <br />❑ Separated Storm Sewer <br />❑ Direct Discharge to Snohomish River or Puget Sound <br />TRIGGERED REQUIREMENTS: <br />❑ MR2 Only ❑ MR1-5 ❑ MR1-9 <br />QUANTITY OF PROPOSED HARD SURFACES: <br />Proposed Roof Area: SF <br />Proposed Hardscape: SF <br />Total New+ Replaced: SF <br />CONTACT INFORMATION <br />OWNER / APPLICANT NAME: C I F,41 C12—'& Co t J TkAC TO R_ S . <br />OWNER / APP. MAILING ADDRESS: STREET 3 Z. v 3 15 +`` S-T- <br />eq <br />CITY C_?_ 7r STATE LAJA. ZIP ! q � Zo <br />OWNER / APP. PHONE: Z O(p - 42- 3 9 9 to i- <br />OWNER / APP. EMAIL: PI%U-L- �—® C1e4e_GP_E t j�COA/. CONI <br />'Required for Work in Public Right -of -Way <br />CONTRACTOR NAME: I i;7Ae CatFtC1Z, CoAlTo4cT-ri 2-s <br />CONTRACTOR ADDRESS: STREET Z d 3 t �" S T_ <br />�l�S <br />n a 'f I <br />CITY ��/(�� 16 STATE p'� - ZIP [ v 6 <br />CONTRACTOR PHONE: (OP — CQSC( -� 2`-1. S `] <br />3 <br />CONTRACTOR EMAIL: PAU.LC C 165,4(ZC12-S E KCorJ • CONi <br />CONTRACTOR LICENSE #(REQUIRED): C1_6A RC ) Z V_ rt <br />EVERETT BUSINESS LICENSE #(REQUIRED): (D _ 84199 <br />PRIMARY CONTACT: ❑ OWNER / APPLICANT CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: <br />C U [Lt�i l <br />TACT PHONE: Z,0� <br />LCONTACT EMAIL: a0/11tiC,G C(,4d2 C/Z /<Cvn] . C d M <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. 1 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 />Agent Signature <br />PERMIT # <br />�r 2; PW.ZIb�-bf <br />Date (Revised 1172019) <br />