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PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETTeVBMmLLINSTRUCTMNe Fm>II>ppR>iwcfl>uErtAI.IEaumen6b F.mil5>rvlwsMB.BmiN>.govc,Orcpall>I3tOn C•W,S„M2nEFW,UCPPa, <br />CONTACT INFORMATION(P)02L25P88101(E)Pe,mdSewices®evere .govl(W)everelMa.gmlPo=IN <br />PROJECT SI <br />PROJECT ADDRESS:620 Millwright Loop North, Everett WA <br />SITE WORK FOR PROJECT TYPE: OSFR-DETACHED OTOWNHOUSE OWPLE% DADU OMULTW MILY OCOMMERCIAL OINDUSTRIAL <br />IF APPLICABLE: O LAND USE PROJECT# (SEPA. PREAPP, sS, ETC.) <br />IF APPLICABLE: [FRANCHISEIUTILITY COMPANY, ANNUAL BLANKET PERMIT# <br />UTILITY COMPANYS NAME a JOB#: JOBM <br />or DESCRIPTION OF sl <br />FILL IN ALL QUANTITIES OF WORK BE LOW, AS APPLICABLE: <br />O FENCE IN ROW FT IN HEIGHT <br />❑ DRIVEWAY APRON I CURB CUT FT WIDE <br />O ASPHALT I CONCRETE PAVING SF <br />D RETAINING WALL I ROCKERY IN RIGHT-OF-WAY _LF <br />❑ RETAINING WALL I ROCKERY OVER CFT IN HEIGHT FT TOTAL HEIGHT <br />■ CLEARING I GRADING I FILL I EXCAVATE 20 CY <br />❑ CUTBORE IN PAVEMENT (PARALLEL) LF <br />O CUTBORE IN PAVEMENT (NON -PARALLEL) LF <br />D POLE WORK I AERIAL I OVERIA$H LF <br />ADDITIONAL DESCRIPTION IAS NEEDED): <br />F-WAY WORK <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO: <br />13 CombYNSewer <br />■ Selxaraord From Serer <br />O Dead Discharge to SmMmw Rrox a PuaM Sound <br />TRIGGERED REQUIREMENTS: <br />OMPEOIy DNI DMBIA <br />QUANTTTY OF PROPOSED HARD SURFACES' <br />Proposed Root Area: SF <br />Proposed Hardenepe: SF <br />Tonl own, Replaced'. SF <br />The existing sanitary sewer lift station adjacent to Boxcar park has failed. <br />This project involves the removal and <br />rep acement of this lift station. I rus pmlect IS CIaSSItIeQ1 as an underground <br />utility project that replaces the group <br />CONTACT INFORMATION <br />OWNER I APPLICANT NAME: Pon of Everefl <br />OWNER/APP. MALINGADDRESS: ¢r_rr PO Box 538 <br />Everefl <br />STATEWA ne 982OE <br />OWNER I APP. PHONE: 425.259.3164 <br />OWNERIAPP. EMAIL: elleeg@poltoleveRr-COM <br />'Required for Work In Public RigMM-Way <br />CONTRACTOR NAME: TIED <br />CONTRACTORADDRESS: STREET <br />ran, <br />STAM <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LICENSE #IREDUIRED: <br />EVERETT BUSINESS LICENSE AREOUIREOI: <br />PRIMARY CONTACT: Q OWNER I APPLICANT ❑CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: Elise GrOn PiWald <br />CONTACT PH ONE:<25.333.U530 <br />CONTACT EMAIL:•INy®warm+wwnmmm <br />ACKNOWLEDGEMEW. I have reviewed this evulka u ka and confirm the irdorma(mn contained M1erein is hue aM mane(. WoorMne pun k and io this nevermore <br />romplY MM cuneM lMnB1, Sua BMbcrdalbr TR greer aw Oka pemMherany lwds9¢pynv¢tl,uWkaMnO tl¢NBEbn41M IT'n. 0¢vIBtW,9 mWf flmf bC <br />aenbarn dinake krwho Meokanirg In <br />eNhak the State Qoncidors Low1Iam IC ord2W1am au(M1orhetlby MBOnraIW(M1isprrcMy fo <br />tarve <br />perform Ilre wcM brwM1eM1 applkalion k made, and; cri„mplY wIM the Stale COntxclors Law 182] RCW erM 296.200A WAC. <br />Ciryo(EverWl 011rciel Use OMy <br />PIEKMI <br />Elise Gronewald 3/29/23 IPW <br />OeaerlAufbO,i,od Agent Signature D41B (Revised 42IM22) <br />