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PW3LIC WORKS PERMIT MPLICATION <br />CITY OF EVERETT PERMIT SER ICES <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 INFOnRMATION <br />PROJECT ADDRESS: ? 13 r �� w "I 2% 1 <br />SITE WORK FOR P CT TYPE: R-DETACHED WNHOUSE PLEX U LTI-FAMILY MMERCIAL USTRIAL <br />IF APPLICABLE: ND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />IF APPLICABLE: ANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # <br />UTILITY COMPANY'S NAME & JOB M JOB # <br />DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <br />FILL <br />IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />NCE IN ROW FT IN HEIGHT <br />IVEWAY APRON /CURB CUT FT WIDE <br />PHALT / CONCRETE PAVING (I� 5m SIF <br />TAINING WALL / ROCKERY IN RIGHT-OF-WAY LF <br />TAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />-EARING / GRADING / FILL / EXCAVATE CY <br />T/BORE IN PAVEMENT (PARALLEL) LF <br />T/BORE IN PAVEMENT (NON -PARALLEL) LF <br />WORK / AERIAL / OVERLASH LF <br />ITIONAL DESCRIPTION (AS NEEDED): <br />DRAINAGE MITIGATION QUESTIONS: <br />MWATER DISCHARGES TO: <br />mbined Sewer <br />parated Storm Sewer <br />rect Discharge to Snohomish River or Puget Sound <br />aGERED8EDIAREMENTS- <br />2 Only R1-5 1-9 <br />L—JDLE <br />QUANTITY OF PROPOSED HARD SURFACES: <br />Proposed Roof Area: SF <br />Proposed Hardscape: SOG SF <br />Total New+ Replaced: vro� SF <br />AD <br />i ALL k LCL4 (-LP Ck C, Lf 1� !� k�'� L�J L')l'V/'( W Ct (4 <br />CONTACT INFORMATION <br />OWNER / APPLICANT NAME: -e'r \ �k--e'r 1 cy-A <br />OWNER I APP. MAILING ADDRESS: STREET <br />CITY J STATE Vl/ ZIP <br />OWNER I APP. PHONE: lQ� S" ,g23S <br />OWNER I APP. EMAIL: (� I C� (i t(2� I P / lotKY)LI f' . CUi'Y� <br />*Required for Work in Public Right -of -Way <br />CONTRACTOR NAME: ei <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LICENSE QUIRED): EVERETT BUSINESS LICENSE #(REQUIRED): <br />PRIMARY CONTACT: NER / APPLICANT NTRACTOR HER (Architect, Engineer, Etc.) <br />CONTACT NAME: p I de <br />r ` Ly l (-n <br />" 1 CONTACT PHONE: V 6 - S7 q _ 2 �5 <br />CONTACT EMAIL: ! Cf kj()991e q <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. l am the owner, or / am authorized by the owner of this property to <br />perform the work for which application is made, and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC, <br />Owner/Authorized Agent Signature <br />City of Everett Official Use Only <br />PERMIT # <br />PW ?!i - OZ� <br />(Revised 1172019) <br />