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10177- KWIC WORKS PERMIT AIILICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ;1 q \'!I Ivo c(C h) I V(? . E\e tr e ft pj,, qcl'!-('r " . SITE WORK FOR PROJECT TYPE: XSFR-DETACHED ❑TOWNHOUSE ['DUPLEX EADU EMULTI-FAMILY ['COMMERCIAL ['INDUSTRIAL IF APPLICABLE: p LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) j 1i I IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# UTILITY COMPANY'S NAME&JOB#: JOB# DESCRIPTION OF SITE WORK / RIGHT-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 El Combined Sewer ❑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 I FILL/EXCAVATE CY El MR2 Only ❑MR1-5 ❑ MR1-9 ❑CUT/BORE IN PAVEMENT(PARALLEL) 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: SF CONTACT INFORMATION OWNER!APPLICANT NAME: pf,(\i.i ' v \^ ) OWNER/APP. MAILING ADDRESS: STREET `i 41 ��))\N j 1�"- rc( A- - STATE CITY tY `.1 L l/i v V A ZIP %�'". OWNER!APP. PHONE: q'Z I `i OWNER/APP.EMAIL: J-`'r,A V 5 Th 6 t)mil I I. ( o *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: El OWNER /APPLICANT ❑ CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: 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# tK. r �--r- 1C-11.1 PW l at 1 t f iD (o Owner/Authorized Agent Signature Date (Revised 1/72019) 2