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• • <br /> 4ren- PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT ADDRESS: :;- 23/1 m E 24Z(L t �' _ e - J (2ooc: ) <br /> SITE WORK FOR PROJECT TYPE: ESFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY'ZCOMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: ❑LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> ❑FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE ❑Combined Sewer <br /> ❑ASPHALT/CONCRETE PAVING SF ❑Separated Storm Sewer <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑Direct Discharge to Snohomish River or Puget Sound <br /> El RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> ❑CLEARING/GRA��jjDI�NGG!!/FILL/EXCAVATE 1 CY CI MR2 Only ❑ MR1-5 CI MR1-9 <br /> ❑CUT/BORE IN PAVEMENT((PARALLEL) 16— LF QUANTITY OF PROPOSED HARD SURFACES: <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF <br /> ❑POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> Ireg4 ZV N ;V i UL SS (v-?,'v) P -ciN b (N)a f x 3` f-fAiv) tivi 71 (AlregtePT(g.um y) )�-11 (() s/fl- p�/1-GuJ1! 16" (N if (APPIA .r�L17�Na�� ��l /- P /IOLc- <br /> ID P/� ,,i2 l✓tI7e. WI' W a 11 :. fEPi ii AiiG Kam) <br /> MOW LuinS ce 2 vie, DN i i_F c)f VW ZoN L g,CL <br /> OWNER/APPLICANT NAME: � <br /> OWNER/APP. MAILING ADDRESS: STREET 3 s 1)1 t i f'V E N., i (� l o C <br /> CITY Sc TZE- STATE t i. q ZIPe:/ f j 03 <br /> OWNER/APP.PHONE: )J)ti (,e tel 0'7 et 6 OWNER/APP.EMAIL: 4/ W M'',(OL Oa 41 L -(CYZAL-) <br /> *Required for Work in Public Right-of-Way n'l /1 p 1� <br /> CONTRACTOR NAME: TM LOOM APQP4M-L-- OF re1�N« J A co p Consttt1 n t n C. <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): Pi CO NW.1. S01.C.1 EVERETT BUSINESS LICENSE#(REQUIRED): ye(Izlp4' 13 <br /> PRIMARY CONTACT: OWNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect, Engineer,Etc.) <br /> CONTACT NAME: ,, Z CONTACT PHONE: lob? (owl�6 <br /> e�P�rAi 1-40W K CONTACT EMAIL: giX"r✓Iel0 @ I t r r(/+,(L.cArk <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done 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 therefrom.Deviations must first be <br /> 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 <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 /> .2 f3t i PW i q D -O P3 <br /> Owner/Authoriz Agent Signature ate (Revised 1/72019) <br />