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MINES <br />PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT <br />3200 CEDAR STREET, EVERII WA III <br />WASH ING TON <br />(P)425-257-81110 I FAX425-25]-085] �(E)BvxelleDel)�everettwe.9Ov HHDsalevae#Ra.90vlpeTmiM <br />PROJECTAODRES3: 3102 ROCkB(BIIBr AVBRUB EV Qt <br />SITE WORK FOR PROJECT TYPE: CISFR-DETACHED OTONMIOUSE ODUPLEX [3ADU DMULTuNAMII-Y>14MMENi OINDUSTRIAL <br />IFAPPLICABLE:11IANDUEEPROJECTA(SEPA,PRE-APP,SG,ETC.1 <br />PAPPLICABLE:❑FRMJLHISEMUWCCARANY,ANNUALBLANKETPERMITO <br />UTKT' COMPANY'S NAME A JOB A: JOB# <br />DESCRIPTION OF SITE WORK I RIONTAF-WAY <br />WORK <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATEROISCHARGES TO: <br />❑Combined Sewer <br />❑ SmpamMd Slam Sommer <br />❑DlOW DY to SnMonYN RXer Or RAM SauM <br />FILL IN ALL QUANTITIES OF WORK 9E PP.LIGABBLE: [(�w' ��N /y+ <br />IIIFENLEIN ROW ��.FAfl.'dLS��iCJT iGJ�'FI NNEGIGHTTrr" <br />/❑"DRIVEWAYAPRONICURSC� by FTWIDE <br />❑ASPHALTICONCRETEPAVING SF <br />❑ RETAINING WALL I ROCKERY IN RIGHTLOF.WAY _IF <br />O RETAINING WALL I ROCKERY OVER 417 IN HEIGHT _FTTOTALHEIOHT <br />❑ CLEARING I GRADING I FILL I EXCAVATE CY <br />❑ CUDHORE IN PAVEMENT (PARALLEL) LF <br />❑ CI.PPBCRE IN PAVEMENT(NON-PARALLEL) LF <br />❑ POLE WORK I AERIAL I OVERVSH IF <br />ADMONAL DESCRIPTION AS NEEOEO: <br />TRIGGEREUREOUIREMENTS <br />❑MR20M OMR14 ❑MRIA <br />OUANTRYOFPROPoSEDHARDSURFACES: <br />prcpcmm]Rod Arm SF <br />PnrywpJ lYrnscom: SF <br />TmMNwxa Re w1 IF, <br />��.a <br />^V ✓� <br />CONTACT <br />FORMATION I <br />OWNERIAPPLILAHT NAME: O/I.II <br />OWNERIAPP. MAIUNGAOORESB: Timm t G <br />STATE !i <br />Our,�) <br />p <br />OWNER/APP. PHONE ZJ A-�ZIp ZS <br />� �� <br />OWNERIAPREMNL (—i"Fpov C (.�M1iliN. <br />'RepuirW for WOM In Public Rlg//Mt�al-Way <br />CONTRACTORNAME: e 1.e F� 1"I <br />CONTRACTORADDRESS:'9 <br />TE CAI <br />nGO <br />CONTRACTOR PHONE: µ/ T l CONTRACTOR EMAIL: I as IW6< <C <br />CONTRACTOR LICENSE #(REQUIRED): <br />I EVERETT BUSINESS LICENSE #(REQUIRED): <br />PRIMARY CONTACT: OWNER/APPLICANT ❑CONTRACTOR ❑ OTHER(Amhllecl, ElpineeL Elo.) <br />CONTACT NAME: ,a J <br />J`1A/L/KnYJW�VI/l <br />CONTACT PHONE: Z.fZIL! ?j <br />CONTACT EMAIL: mow— <br />ACKWOM-EAGEMENT lllere nuawd Mu epplcanon andcm/mm IM inbcme(ion conlvinaEhenMia Irte and ciFinal WdN dmepurwM b M'FpemH mutl <br />cunply mM uuranl MMaI SAW, wilkul4w, fie granting Wepmtif only aulMnrea approved wR and no deNebbna ffieni Mvielkna mu9Nefb <br />amlmnd in wnmM RumWe BUYw.p Ommdmde homeaonpned under any oiroummlanra.i.m nla ow.wco-Iem aWMrtV q. me oxenralroa pmpanym <br />pan mImw rww �a amax,and IaompiywirowSraNCm ore Law+a2TRCWand2se.2 WAC <br />,7 mEa.an C#v's11M a:y <br />i� I IPERI <br />JAi Ipw <br />OwnerlAUllnrlad Agency MPMum Maymbad l/IMIg) <br />