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0 <br />EVERETT <br />WASHINGTON <br />PIPLIC WORKS PERMIT 10PLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(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: L <br />ZL> <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU []MULTI -FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br />IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />'DESCRIPTION OF,SITE WORK"/ RIGHT OF: INAY W�"3RK <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 ('J Z LF <br />❑ RETAINING WALL I 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 />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: SF <br />Proposed Hardscape: SF <br />Total New+ Replaced: SF <br />CONTACT INFORMATION <br />OWNER / APPLICANT NAME: <br />OWNER / APP. MAILING ADDRESS: STREET 3(0)n41/ C " <br />CITY �i �,�T <br />/per Z <br />STATE / J ZIP ?_C� <br />OWNER / APP. PHONE: L' 2':�2- j - 2 OWNER / APP. EMAIL: S <br />Id-6a <br />Re uired for Work in Public * Right -of -Way q f-Way <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET <br />CITY <br />STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LICENSE #(REQUIRED): <br />EVERETT BUSINESS LICENSE #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER / APPLICANT ❑ CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />ACKNOWLEDGEMENT. 1 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 />PERMIT # <br />2 1 Y Z-4--1 PW z e.7,p - r <br />Owner/Authorized Agent Signatilrre Date (Revised 411512019) <br />