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PUtIC WORKS PERMIT A'LICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT SITE°INFORMATION: PROJECT ADDRESS: Q(O $ Y 7-4 3 A SITE WORK FOR PROJECT TYPE: E1SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX DADU ❑MULTI-FAMILY ❑COMMERCIAL DINDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) $ LA$ /✓o. ) 8'- DO,2- DESCRIPTION OF SITEWORK:TRIGHT OF WAY WORK FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: ❑ FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: ❑ DRIVEWAY APRON/CURB CUT FT WIDE ❑Combined Sewer El ASPHALT/CONCRETE PAVING SF Separated Storm Sewer ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑ Direct Discharge to Snohomish River or Puget Sound ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: ❑CLEARING/GRADING/FILL/EXCAVATE CY ❑ MR2 Only ❑ MR1-5 ❑ MR1-9 m CUT/BORE IN PAVEMENT(PARALLEL) X.. I) LF QUANTITY OF PROPOSED HARD SURFACES: ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF ❑ POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: 0 SF 1'h .1) -✓cr 1? e.�.sto^ \o q 6 CONTACT�'INFOR A'TION.... . OWNER/APPLICANT NAME: l'y e( S�-onei .•0 L Le, OWNER/APP. MAILING ADDRESS: STREETT 3 'O,S— S^..o I/,ey Po , .. f )3I c • (� 7 CITY iY\cA / S V 1 I I . / STATE �" ZIP 9 a �/I/ OWNER/APP.PHONE: 3 6 U Gs 9 q'7f 4 `/ OWNER/APP. EMAIL: *Required for Work in Public Right-of-Way CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): PRIMARY CONTACT: 18 OWNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: 360- 4,.$ — 9 y y,./ v k CONTACT EMAIL: 7 0.....-1 no - )'S411.yS I-a..cam,••• i . es.� ACKNOWLEDGEMENT.I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must 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 authorized in writing from the Building Official before being authorized under any circumstance. I am the owner, or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only / PERMIT# a-5,„ 1-/J-ZOZo PW 2001-��1 Ow r/ horized Agent Signature Date (Revised 4/15/2019) • '