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POBLIC WORKS PERMIT OPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 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 lNfORM' 16N <br />PROJECT ADDRESS: Zj <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE []DUPLEX ❑ADU CIMULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br />IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />DESCRIPTION OF SITE WOR10 RIGHT OF-VIIAY 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 g01/0 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 />CONT//ACT RNFt?IiMAltIdi <br />OWNER / APPLICANT NAME: C� <br />OWNER / APP. MAILING ADDRESS: STREET <br />In,U <br />CITY �/ V h'J I�-� L-' dr'✓�C STATE 'Y ZIP /u <br />OWNER / APP. PHONE: ,�i f!6 �9 - �a OWNER / APP. EMAIL: <br />`Required for Work in Public Right -of -Way 1 <br />CONTRACTOR NAME: -1 7t-" 6 <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: -rA <br />CONTRACTOR LICENSE #(REQUIRED): �—��� 13 L I Q_ iZ_ <br />EVERETT BUSINESS LICENSE #(REQUIRED) <br />PRIMARY CONTACT: NER / APPLICANT ONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: n % <br />1 JG`-�SS -1) <br />CONTACT PHONE: ` - 3'0 <br />CONTACT EMAIL: j� -�} j li' W elO <br />ACKNOWLEDGEMENT.' I 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 1 am authorized by the owner of this property to <br />perform the work for yvhich 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 />Z�z Pwtzool <br />Agent Signature Date (Revised 411512019) <br />�/ 1 <br />