4201 RUCKER AVE COMMUNITY HEALTH CENTER 2022-10-07

E V E R E T T PUBLIC WORKS REVIEW WORKSHEET WASHINGTON PROJECT ADDRESS: 4201 RUCKER AVE FLRS 1 & 3 Permit#: B2112-008 TENANT: COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY DESCRIPTION OF WORK: REMODEL EXTG MEDICAL OFFICE FOR USE AS A MEDICAL CLINIC PW Reviewer to select all that apply below: Utility Permits (Note:Permit Technicians to Create Utility Permit for Sewer, Water, Fire, and Irrigation, as selected below) SANITARY SEWER: DOMESTIC WATER SERVICE: (Attach Calculation& Cost Est.) ❑ New Connection to main plus connections to building ❑ New Connection, Size -❑ Per Cost Estimate ❑Alteration ❑ Meter Only, Size -❑ Per Cost Estimate ❑ Repair 0 Water System Development Fee Total:$ ❑ Cap-off,quantity 0 Sewer System Development Fee Total:$ ❑ Reconnection to stub 0 Water Service Line(behind meter), Size ❑ Backwater Valve ❑ Backflow Prevention (Outside Building): ❑ RPBA or 0 DCVA ANOT REQUIRED ''IOT REQUIRED Explanation/Utility Permit#: Explanation/Utility Permit#: IRRIGATION SERVICE: (Not Including Cost Estimates) FIRE SERVICE: (Attach Cost Estimate/Request for Reference) ❑ New Connection, Size ❑ New Connection, Size -❑ Per Cost Estimate ❑Meter Only, Size ❑'/"Detect Meter Only, Service Size ❑Water System Development Fee Total:$ ❑ Backflow Prevention (Outside Building): 0 DCDA ❑ Backflow Prevention (Outside Building): 0 DCVA ANOT REQUIRED XNOT REQUIRED Explanation/Utility Permit#: Explanation/Utility Permit#: WATER DEPARTMENT COST ESTIMATE NEEDED-(If yes, PW Reviewer to send cost estimate request to Water Department) ❑Yes,Quantity , See attached for reference. )(NOT REQUIRED Plumbing Permits (Note:Permit Technicians to add all items selected below to Plumbing Permit-for items inside building only) ,143 ackflow Prevention (Inside Building): 0 DCVA(for Domestic service) 0 RPBA(for Domestic service) ❑ DCDA(for Fire service) ❑ NOT REQUIRED P G 2 9 Building Permits (Note:Permit Technicians to add all items selected below to associated Building Permit) STORMWATER SYSTEM DEVELOPMENT FEES: TRAFFIC MITIGATION FEES: ❑YES, 0 See Attached for calculations/credit 0 YES,Traffic Mitigation Total: $ To be added on PW To be added on 0 See Attached for calculations/credit Quantity charged SF Quantity charged SF tif NOT REQUIRED QTY is 0 Ground only 0 all hard surfaces QTY is 0 Roof only 0 all hard surfaces $ $ ANOT REQUIRED Additional Checklists: ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) ❑YES—TYPE: 0 SFR ❑DUPLEX 0 ADU 0 INFILL DWELLING 0 MULTI-FAMILY 0 COMMERCIAL ❑See Attached Letter,2 copies (Permit Techs to issue one copy to applicant with permits, scan one copy to Jeffrey Marks) ❑ Digital copy attached to permit record, Permit# ❑Saved to Address Folder in Development Tech File XNOT REQUIRED FIRE SPRINKLERS REQUIRED? ❑YES—Type NOT REQUIRED Reason: PUBLIC WORKS PERMIT REQUIRED? ❑YES, Permit#PW ❑ Stormwater NPDES Tab Completed in TRAKiT 0 ADA Tab Completed in TRAKiT 0 Inspections Added in TRAKiT ,$NOT REQUIRED Worksheet Completed By: Ai Y - `ScsZa��_ Date: in.//Zo,�j d 7 '2-- Worksheet Checked By: U ( Date: