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PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETTSUBMITTAL IN STRUCTIONS: EmN aIMIwWn& suOmNel EocumeMs APe arvkes®avail gov or drop a el ffiW Ceder Sited Won Slope, Drop Box <br />WASHINGTON CONTACT INFORMATION: IN) 425-P5T-OB101(E)Pannll5ervkee®everaXvegov l lAl evereRm.Owlpennllfl <br />,. wr t R21N1lOY✓tm <br />PROJECT ADDRESS: /io2. r 1 ,(!(/Q,', <br />W OZO <br />SITE WORK FOR PROJECT TYPE: DSFRDETAOHED OTOWNHOUSE DDUPLEX OADU OMULTI-FAMILY OCOMMERCIAL DINDUSTRIAL <br />WAPPLICABLE: ❑ LAND USE PRQIECTO(SEPA, PRE-APP, SS, ETC.) <br />IFAPPLICABLE: ❑FRANCHISEA)TILITYCOMPANY, ANNUAL BLANKETPERMIT# <br />UTILITY COMPANY'S NAME&JOB#: JOB#: <br />,w eaw.w -m D O dl O O.�$ �EiN$RI 4PlI H.. <br />FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />❑ FENCE IN ROW FT IN HEIGHT <br />❑ DRIVEWAY APRON I CURB CUT uq J� FTWIDE <br />® ASPHALT I CONCRETE PAVING / �LJ SF <br />❑RETAINING WALL/ ROCKERY IN RIGHT-OF-WAY _LF <br />❑RETAINING WALL/ ROCKERY OVER 4FT IN HEIGHT AFT TOTAL HEIGHT <br />❑ CLEARING / GRADING I FILL I EXCAVATE CY <br />❑ CUTIBORE IN PAVEMENT (PARALLEL) LF <br />❑ CUTIBORE IN PAVEMENT(NON-PARAI LF <br />❑ POLE WORK I AERIAL I OVERLAGH LF <br />ADDITIONAL DESCRIPTION JANIS NEEDED: <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO. <br />❑Comhlned Sewer <br />O Sepamped Sbrm Sewer <br />O Direct Discharge to Snolwmbh RNx or Pupal Sound <br />TRIGGERED REQUIREMENTS: <br />❑MRx Only OMR1S ❑MI <br />QUANTITY OF PROPOSED HARD SURFACES: <br />Properaed Root Area: SF <br />Proposed Hardheaded: sF <br />Total Naw+Regttetl: SF <br />§ el ? <br />OWNERIAPPUCANT NAME, <br />OWNER I APP. MAILING ADDRESS <br />arArt <br />OWNER IAPP. PHONE: dJ' SOcS jU OWNER/APP.EMAIL; <br />!1 /( <br />.. _ ._.... _..... _.__.__ .. <br />'Required for Work in Pupllc RightI-Way <br />CONTRACTORNAME: <br />CONTRACTOR ADDRESS: aTn¢T <br />MIT <br />STATE P <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LICENSE R(REOUIRED): <br />EVERETT BUSINESS LICENSE Y(REQUIRED):. <br />PRIMARY CONTACT WNER/APPLICANT ❑CONTRACTOR ❑ OTHER(Amh]Wc4 EnTnear, Etc.) <br />C T TNAME: 4 I <br />IA,hCONTACTEMAIL: <br />CONTACTPHONE: <br />-3 <br />l <br />C <br />@ 2 <br />Q <br />wawedlhis aypNcalmn and sorllrm the ny meWn cunlalned hereto la hue and correct aw" Jorge Wnuanl so and permit most <br />Brad local law. Me gmRf* Are, Pe OMy eWhWims epprpwd Week and nodeviagons lhemt .Oevleflolu met Get As <br />and 2962004 WAC <br />GIy WEveral Most Use Oney <br />PERMIT# <br />PW 23c3 0(T5g <br />(ReWednal/ 22) <br />