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ini BLIC WORKS PERMIT OPPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> E V E R E T T 3200 CEDAR STREET, EVERETT, WA 98201 <br /> WASH INGTON (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 2c,53- C et - vue� " oric3g20 I <br /> SITE WORK FOR PROJECT TYPE: FR-DETACHE OWNHOUSEDUPLEDU 1ULTl-FACIA VDUSTRIAL <br /> IF APPLICABLE: ND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> IF APPLICABLE: [}RANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> ENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> RIVEWAY APRON/CURB CUT FT WIDE combined Sewer <br /> SPHALT/CONCRETE PAVING 107 I SF 'eparated Storm Sewer <br /> ETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF Direct Discharge to Snohomish River or Puget Sound <br /> DETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> LEARING/GRADING/FILL/EXCAVATE CY VIR2 Only [ 1R15 LifR1-9 <br /> UT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> UT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF <br /> OLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: (Ictvic,q ©fsOK, <br /> OWNER/APP. MAILING ADDRESS: STREET ' <br /> r 0'* Si-- <br /> CITY .5v STATE VV ft ZIIVO / <br /> OWNER/APP. PHONE: (tIS2.B! 1fY(03 OWNER/APP. EMAIL: Nyrterif, Cle 1,( I C.o'.A- <br /> *Required for Work in Public Right-of-W y (LOV-IS'41UCJ1 <br /> CONTRACTOR NAME: rSO 1 <br /> c Avf,CONTRACTOR ADDRESS: sTREET 3 4 3r n p <br /> CITY Letkc Si PAA OJ STATE (AP ZIPcg2Z <br /> CONTRACTOR PHONE: (tjz ) 2z1-421qi CONTRACTOR EMAIL: C,vr e'S( Cj r i cor7sfrtAdiofri . tt <br /> CONTRACTOR LICENSE#(REQUIRED):CC,COiPT/w 1-I SPA EVERETT BUSINESS LICENSE#(REQUIRED):M/563 <br /> PRIMARY CONTACT: [ThWNER /APPLICANT CONTRACTOR ISTDTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: 0426) 28�0_ cy <br /> /y <br /> w • <br /> �1 C1 I Qi�l�l�L�1Ci CONTACT EMAIL: i (eoLrc, t . flir .( (i3Og,t, <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Wo ••ne 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 there rom. Deviations must first be <br /> authorized in writing from the Building Official before being authorized under any circumstance. I am the owner. or/am authorized by the owner of this property to <br /> perform the work for which 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 /> PW A0t - 01f <br /> 01JZ41 <br /> rized A t ure LOW Co - q -_V � <br /> Date (Revised 1/72019) <br />