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110 PUBLIC WORKS S <br /> REVIEW WORKSHEET <br /> (ATTACH 1 SITE PLAN FOR REVIEW) Date: 3/9/2016 <br /> Permit#: B1603-024 <br /> PROJECT ADDRESS: 1330 ROCKEFELLER AVE 3RD FL DESCRIPTION OF WORK: TI FOR NEW MEDICAL CLINIC ON 3RD FL OF EXTG-PRMC I D I I``a / I <br /> CONTACT INFORMATION: <br /> OWNER: APPLICANT: <br /> NAME: PROVIDENCE HEALTH&SERVICES NAME: SAYLOR DEVIN <br /> ADDRESS: 1801 LIND AVE SW#9016 ADDRESS: <br /> RENTON,WA,98057 , <br /> PHONE: PHONE: 4252590868 <br /> EMAIL: EMAIL: DEVIN@BNHARCH.COM <br /> CONTACT: ❑ Owner ❑ Applicant ❑Other <br /> NAME: [ContactName] <br /> PHONE: [ContactPhone] <br /> EMAIL: [ContactEmail] <br /> COMMENTS FROM PUBLIC WORKS REVIEWER: LAND USE PROJECT#: <br /> PW Permit Required? ❑ YES 'NO W.O.#: <br /> Notes: go pa) etyntA AA Associated Bldg./PW Permit#: <br /> FIRE SPRINKLER REQUIRED?(by Fire Department/Code) <br /> ❑ ES—Type (If yes,add to TRAKiT under Reviewer Comments on Bldg Permit and Stamp,WNO � o� <br /> Explanation: �/StfSS 4, Lj <br /> (Note: Counter Staff to Create(`I`ility Permit for anyG(,Wa'ter/Sewer/System Development Fees) <br /> WATER FEES? <br /> DOMESTIC SERVICE: FIRE SERVICE: <br /> ❑YES—Amount$ 0 YES—Amount$ <br /> 0 Meter Only, 0 Complete Service, Size 0 3/" Detect Meter Only, 0 Fire Service Size <br /> 'NO 'NO <br /> Explanation: Explanation: <br /> ❑Water Department Cost Estimate Needed-Of yes, PW Reviewer to send cost estimate request to Water Department, attach copy) <br /> Existing Utility Permit#(if applicable): <br /> SEWER FEE? <br /> ❑YES—Amount$ 0 New Connection, 0 Alteration/Repair, 0 Cap-off/Reconnect <br /> la/NO <br /> Explanation: <br /> Existing Utility Permit#(if applicable): <br /> SYSTEM DEVELOPMENT FEE? <br /> ❑YES—Amount$ 0 See Attached Spreadsheet <br /> 'NO—No Change of Use/Other <br /> Explanation: <br /> (Note:Public Works Reviewer to Add Traffic Mitigation to PW Permit(if applicable)) <br /> TRAFFIC MITIGATION FEE? <br /> ❑YES—Amount$ 0 See Attached Spreadsheet <br /> >i NO <br /> ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) <br /> ❑YES—TYPE 0 See Attached Letter <br /> tit NO <br /> Public Works Reviewer Signature Date <br /> REVISED 2/24/2016 <br />