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0 <br />PUBLIC WORKS PERMIT APPLICATION <br />EVERETT <br />CITY OF EVERETT PERMIT SERVICES <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: j Z 3 C) Ec1S', 1!-X C C, � -I I -7 C, C 0 -7 C, <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED CITOWNHOUSE [-]DUPLEX ❑ADU [-IMULTI-FAMILY ❑COMMERCIAL []INDUSTRIAL <br />IF APPLICABLE: ::] LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />LAPPLICABLE: ❑ FRANCHISEWTILITY 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 L CY <br />❑ CUT/BORE IN PAVEMENT (PARALLEL) LF <br />ElCUT/BORE IN PAVEMENT (NON -PARALLEL) LF <br />❑ POLE WORK / AERIAL / OVERLASH LF <br />ADDITIONAL DESCRIPTION (AS NEEDED): <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWA TER 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: '2- 1 ' t 1 sSF <br />Proposed Hardscape:_ i �+ 1 5 SF <br />L Total New+ Replaced: 1 7 SF <br />New SFR I—C .; '-1 <br />CONTACT INFORMATION <br />OWNER I APPLICANT NAME:t(� <br />OWNER / APP. MAILING ADDRESS: STREET,C- 302 IE/(�. `-A T t) .i, -T Ll C 1n/ <br />CITY e j �i � � - STATE v A ZIP 982 <br />OWNER I APP. PHONE: 425-2090-2429 <br />OWNER / APP. EMAIL:Ioel@haaCkbrotherS.Com <br />`Required for Work in Public Right -of -Way <br />CONTRACTOR NAME: Haack Brothers Homes <br />CONTRACTOR ADDRESS: STREET3922 87th AVE NE <br />CITY Marysville STATE WA 7IP 98270 <br />CONTRACTOR PHONE: 425-290-2429 <br />CONTRACTOR EMAIL:Ioel@haaCkbrotherS.00171 <br />CONTRACTOR LICENSE #(REQUIRED).HaackB101 2DZ <br />EVERETT BUSINESS LICENSE #(REQUIRED): 053967 <br />PRIMARY CONTACT: ❑ OWNER / APPLICANT g CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: <br />Joel Haack <br />CONTACT PHONE:425-290-2429 <br />CONTACTEMAIL:joel@haackbrotherS.00171 <br />ACKNOWLEDGEMENT. l 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 />rized Agent <br />Date <br />City of Everett Official Use Only <br />PERMIT # <br />PW <br />(Revised 1172019) <br />