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EVERETT <br />PUBLIC WORKS REVIEW WORKSHEET <br />WASHINGTON <br />PROJECT ADDRESS: 1216 BROADWAY Permit #: PW2205-002 <br />TENANT: [TenName) <br />DESCRIPTION OF WORK: INSTALL ASPHALT PAVEMENT TO REPLACE DEMOLISHED BUILDING <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 Syst Development Fee Total: $ <br />❑ Cap -off, uantity ❑ Sewer S errDevelopment Fee Total: $ <br />❑ Reco ection to stub ❑ Water ervice Line (behind meter), Size <br />Bac ater Valve Ba ow Prevention (Outside Building): ❑RPBA ❑ DCVA <br />N REQUIRED T REQUIRED <br />Expl nation/Utility Permit # E anation/Utility Permit # <br />IRRIGATION SERVICE: (Not Including Cost Estima FIRE SERVI : (Attach Cost Estimate / Request for Reference) <br />New Connection, Size" ❑ New C nection, Size - El Per Cost Estimate <br />3/4" <br />❑ Meter Only, Size ❑ D ect Meter Only, Service Size <br />Water System Development Fee Total: �2� ❑DCDA <br />❑ B flow Prevention (Outside Building): <br />Backflow Prevention (Outside Building): DCVA, OT REQUIRED <br />❑ NOT REQUIRED Explanation/Utility Permit # <br />Explanation/Utility Permit # <br />WATER DEPARTMENT COST ESTIMATE NEED -(If yes, PW Reviewer to send cost estimate request to Water Department) <br />Yes, antity , See attached for reference. <br />NOT EQUIRED <br />Plunfbing Permits (Note: Permit Technicians to add all items selected below to Plumbing Permit -for items inside building only) <br />Backflow P vention (Inside Building): ❑DCVA (for Domestic service) ❑RPBA (for Domestic service) ❑DCDA (for Fire service) <br />NOT QUIRED <br />wilding Permits (Note: Permit Technicians to add all items selected below to associated <br />Building Permit) <br />STORMWATER SYSTEM DEVELOPMENT FEES: <br />TRAFFIC MIT ATION FEES: <br />YES, ❑ See Attached for calculations / credit <br />❑ YES, Trpfic Mitigation Total: $ <br />To be added on PW 20 . vo Z To be added on <br />ee Attached for calculations/credit <br />Quantity chargedSF Quantity charged SF <br />QTY is ❑ Ground only ❑ all surfaces QTY is ❑ Roof only ❑ all surfaces <br />NOVREQUIRED <br />2 y31.9` <br />❑ N REQUIRED <br />Additional Checklists: <br />ADDRESS LET R REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) <br />❑ YES ❑ SFR ❑ DUPLEX ❑ ADU ❑ INFILL DWELLING ❑ MULTI -FAMILY ❑ COMMERCIAL <br />❑ See ached Letter, 2 copies (Permit Techs to issue one copy to applicant with permits, scan one copy to Jeffrey Marks) <br />❑ Dig' I copy attached to permit record, Permit # <br />❑ S ed to Address Folder in Development Tech File <br />XNO REQUIRED <br />FIRE SPRIN ERS REQUIRED? <br />❑ YES e <br />NOT /R6IRED <br />Reason: <br />PUBLIC WORKS PERMIT REQUIRED? <br />YES, Permit # PW_Ze_p S'_ 0() Z <br />>1-)Stormwater NPDES Tab Completed in TRAKiT ADA Tab Completed in TRAKiT )4Inspections Added in TRAKiT <br />❑NT REQUIRED <br />Worksheet Completed By: �^ / Date: O :7 - i 2 — 2,o 7 Z <br />Worksheet Completed By: Date: <br />REVISED 1212212021 <br />