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i-9 <br />F_­11 <br />E VE R E T T <br />WASHINGTON PUBLIC WORKS REVIEW WORKSHEET <br />PROJECT ADDRESS: 3314 ROCKEFELLER AVE Permit #: B2005-037 <br />TENANT: [TenName] <br />DESCRIPTION OF WORK: CONVERT EXISTING BASEMENT INTO DWELLING UNIT <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 ❑ New Connection, Size - ❑ Per Cost Estimate <br />❑ Alteration ❑ Meter Only, Size - ❑ Per Cost Estimate <br />❑ Repair ❑ Water System Development Fee Total: $ <br />❑ Cap -off, antity ❑ Sewer Syste Development Fee Total: $ <br />❑ Recon ction to stub ❑Water Se ce Line (behind meter), Size <br />❑ Back ater Valve ❑ Backflo Prevention (Outside Building): ❑ RPBA or ❑ DCVA <br />�O REQUIRED I�IaLOT QUIRED <br />Expl nation/ Utility Permit #: Explan tion/ Utility Permit #: <br />IRRIGATION SERVICE: (Not Including Cost Estimates) FIRE SERVICE: (Attach Cost Estimate l Request for Reference) <br />❑ New Connection, Size ❑ New Connection, Size - ❑ Per Cost Estimate <br />❑ Meter Only, Size ❑ 3/" De <br />t t Meter Only, Service Size <br />❑ Water ystem Development Fee Total: $ ❑ Backf w Prevention (Outside Building): ❑ DCDA <br />❑ Backyow Prevention (Outside Building): ❑ DCVA 6=14eTAREQUIRED <br />{-AIO REQUIRED Expl ation/ Utility Permit #: <br />Explinationif Utility Permit #: <br />WATER DEP RTMENT COST ESTIMATE NEEDED -(If yes, PW Reviewer to send cost estimate request to Water Department) <br />❑ Yes, Qu tity See attached for reference. <br />L��NOT QUIRED <br />Plumbin ermits (Note: Permit Technicians to add all items selected below to Plumbing Permit -for items inside building only) <br />❑ Backflo Prevention (Inside Building): ❑ DCVA (for Domestic service) ❑ RPBA (for Domestic service) ❑ DCDA (for Fire service) <br />KNOT QUIRED <br />Building Permits (Note: Permit Technicians to add all items selected below to as ciated Building Permit) <br />STORMWATER SYSTEM DEVELOPMENT FEES: TRAFFIC MITIGATION FEES: <br />❑ YES, ❑See !ached for calculations / credit DYES, Traffic Mitigation Total: �, (4?.00 <br />To be add on PW To be added on ❑ See Attached for calculations / credit <br />Quantity arged SF Quantity charged F ❑ NOT QUIRED <br />QTY is Ground only ❑ all hard surfaces QTY is ❑ Roof only ❑ all hard surfa es / 2 -�� �Ex f-�V_ <br />$ 1 $ <br />"O EQUIRED <br />nal Chec ► <br />ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from T aa#-Jtl4en incnlude) <br />YES — TYPE: ❑ SFR 9DUPLEX ❑ ADU ❑ INFILL DWELLING ❑ MULTI -FAMILY ❑ COMMERCIAL <br />Of See Attached Letter, 2 copies (Permit Techs to issue one copy to applicant with permits, scan one copy to Jeffrey <br />WF Digital copy attached to permit record, Permit # :azooS' o.3 '1 <br />FLSaved to Address Folder in Development Tech File <br />❑ NOT REQUIRED <br />FI IRE <br />❑ YES —Typ <br />^NOT R UIRED <br />Reason: <br />PUBLIC WORKS PERMIT REQUIRED? <br />❑ YES, Permit # PW <br />❑ Stormwater NPDES Tab Completed in TRAKiT ❑ ADA Tab Completed in TRAKiT ❑ Inspections Added in TRAKiT <br />[RIOT REQUIRED <br />Worksheet Completed By:� Date: D 2�I `F l SoW <br />Worksheet Checked By: Date: <br />REVISED 1112712019 <br />