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0 i <br /> E V E R E T T PUBLIC WORKS REVIEW WORKSHEET <br /> WASHINGTON <br /> PROJECT ADDRESS: 8621 XAVIER WAY Permit#: B2101-022 <br /> TENANT: [TenName] <br /> DESCRIPTION OF WORK: CREATE ADULT FAMILY HOME, INSTALL GRAB BARS AND RAMP <br /> PW Reviewer to select all that apply below: <br /> Utility Permits (Note:Permit Technicians to Create Utility Permit for Sewer, Water, Fire, and Irrigation, as selected below) <br /> SANITARY SEWER: DOMESTIC WATER SERVICE: (Attach Calculation &Cost Est.) <br /> ❑ New Connection to main plus connections to building 0 New Connection, Size -0 Per Cost Estimate <br /> ❑Alteration ❑ Meter Only, Si -0 Per Cost Estimate <br /> ❑ Repair 0 Water Syst Development Fee Total:$ <br /> ❑ Cap-off,qua ty ❑ Sewer S em Development Fee Total: $ <br /> ❑ Reconnect' n to stub 0 Water ervice Line(behind meter), Size <br /> ❑ Backwat Valve 0 Back w Prevention (Outside Building): 0 RPBA or 0 DCVA <br /> NOT R UIRED a% NO REQUIRED <br /> Explana' n/Utility Permit#: Explanation/Utility Permit#: <br /> IRRIGATION SE-VICE: (Not Including Cost Estimates) FIRE SERVICE: (Attach Cost Estimate/Request for Reference) <br /> ❑ New Connec'on, Size 0 New Connection, Size -❑ Per Cost Estimate <br /> ❑ Meter Only ize ❑3/4" Detect ter Only, Service Size <br /> ❑Water Sy em Development Fee Total:$ ❑ Backflow revention (Outside Building): ElDCDA <br /> ElBackflo Prevention (Outside Building): 0 DCVA 4lOT R UIRED <br /> NOT R'QUIRED Explan on/Utility Permit#: <br /> Explanat.n/Utility ermit#: <br /> WATER DEP TMENT COST ESTIMATE NEEDED-(/f yes, PW Reviewer to send cost estimate request to Water Department) <br /> ❑Yes, Quan ty , See attached for reference. <br /> kNOT RE UIRED <br /> Plumb ng P rmits (Note:Permit Technicians to add all items selected below to Plumbing Permit-for items inside building only) <br /> ❑ Backflow P evention (Inside Building): 0 DCVA(for Domestic service) ❑ RPBA(for Domestic service) 0 DCDA(for Fire service) <br /> itg-NOT R UIRED <br /> Building Permits (Note:Permit Technicians to add ems selected below to assocl ted Building Permit) <br /> STORMWATER SYSTEM DEVELOPMENT FEES: T FFIC MITIGATION FEES: <br /> %YES,P(See Attached for c ulations/credit ❑ ES,Traffic Mitigation Total: $ <br /> To be added on PW 2i 4-oo To added on $21v I-0 2 Z. 0 See Attached for calculations/credit <br /> Quantity charged SF Qu tity charged 461 SF OT REQUIRED <br /> QTY is MGround o ❑all hard surfaces QT is 1:5t Roof only❑all hard surfaces <br /> $ 2_3 .O Z $ 12..0.25 <br /> ❑ NOT REQUIRE <br /> Additional Checklists: <br /> ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) <br /> ❑YES-TYPE: ❑ SFR ❑DUPLEX ❑ADU ❑ INFILL DWELLING ❑ MULTI-FAMILY 0 COMMERCIAL <br /> ❑ See A ached Letter,2 copies (Permit Techs to issue one copy to applicant with permits, scan one copy to Jeffrey Marks) <br /> ❑ Digi copy attached to permit record, Permit# <br /> ❑ S ed to Address Folder in Development Tech File <br /> pi-NOT RE IRED <br /> FIRE SPRI K RS REQUIRED? <br /> q.IYES-Ty <br /> .1\10T R UIRED <br /> Reason: <br /> PUBLIC WOR S PERMIT REQUIRED? <br /> 0-YES, Per ' #PW 210 4-owl <br /> tormwater NPDES Tab Completed in TRAKiTDA Tab Completed in TRAKiT ❑ Inspections Added in TRAKiT <br /> ❑ NOT R UIRED _ <br /> Worksheet Completed By: Date: <br /> 64102-1zo2_( 'J l's <br /> /Y , <br /> Worksheet Checked By: Date: L._ --�" <br /> REVISED 11/27/2019 <br />