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PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />E V E R E T T 3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257Ae57 1(E) ever ps@evereflwagov I Mlpsllevere yov/pennHS <br />PROJECT SITE INFORMATION <br />PROJECT ADDRE35: rq1 Lu to erq„ CH urcI, .XTo a Rocke Fe ller Avc. eve m J-f, W4. <br />SITE WORK FOR PROJECTTYPE: [ISM DETACHED OTOVJNIOUSE OOUPUIX QADU m9ULnsAMiLY NCOMUERCIAL EIINDUSIRIAL <br />FAPPLICABLE:❑IANOUSEMWEGT#(SEPA,PREAPP,SS,ETC.) <br />NAPPLICABLE: ❑ FRANCHISEIUTILITYCOMPANY, ANNUAL BLANKET PERMIT# <br />UTILITY COMPANY'S NAME& JOB& JOB# <br />DESCRIPTION OF SITE WORK / RION'T-OFWAT WORK <br />FILL IN ALL QUANTITIES OF WORK BELOW, AB APPICABLE: <br />®FENCE IN ROW 6 FT IN HEIGHT <br />❑DRIVEWAY APRON/CURB CUT FTWIDE <br />❑ASPHALT/ CONCRETE PAVING SF <br />❑ RETAINING WALL I ROCKERY IN RIGHTOF-WAY LF <br />❑ RETAINING WALL I ROCKERY OVER 4FTIN HEIGHT FT TOTAL HEIGHT <br />❑ CLEARING I GRADING I FILL/EXCAVATE CY <br />❑ CITUBORE IN PAVEMENT (PARALLEL) LF <br />❑ CUrIBORE IN PAVEMENT(NON-PARATEL) LF <br />❑ POLE WORK IAERML/OVERIAEH LF <br />ADDITIONAL DESCRIPTION NEEDED: <br />DRAINAGE MITIGATION DUESTgN3: <br />STORMWATER DISCHARGES TO: <br />❑cwnomm 5eaer <br />❑ Sepamtrtl Slwm Sew <br />❑Dim Oe wb Snd ish Riser m Pup&5a <br />TRIGGERED REQUIREMENTS: <br />❑MITE onN OMR15 ElMR1-e <br />QUANTITY OF PROPOSED HARD SURFACES <br />ProposanR Ams SF <br />Prone4 HmMe IaeSF <br />ToW New, aced. w <br />p <br />Shi wlla}�O 0 to ee 1 O Wroq h %peg re({C FOSr <br />wr o In rc ro on k / ve< <br />CONTACT INFORMATION <br />OWNERIAPPLICANT NAME: D7 vV 1- " J 1- A [L <br />OWNERIAPP. MAILINGADDRESS: a%Oa. Ave. <br />a� <br />HYe ret wRae 98ao) <br />OWNERIAPP. PHONE: y-u-Qsa-&ajl OWNERIAPP. EMAIL: C¢nf ra l/u <br />RepuilM 6r WOA in FWD ROMaEway <br />CONTRACTORNAME: wnA Cauntn F—¢ncG <br />CONTRACTORADDREBS: /-} „ a/a t-s $ SW <br />cmr- L STAM W A Y803! <br />CONTRACTOR PHONE Lft S-775- 053j <br />CONTRACTOR EMML In FO fovn.n.L coon}• /-'enee Ne"% <br />OMRACTORLIGENSE#(REQUREO):T WWCrAT 3'«7L7 <br />EYERETT BUSIN65s ucCw;E i(REOUMED): 036533 <br />PRIMARYCONTACT: ® OWNER /APPLICANT ❑CONTRACTOR ❑ OTHER (ArcM1ilecl, El19in .ER) <br />CONTACT NAME: <br />Dave r;nst-Ad <br />CONTACT PHONE: J QS S <br />CONTACTEMNL ca l,dO daVG(� wd I- cv. <br />ALY(IW4KEOGEMEM Inane mvicaed(Maarydna#an andmAun the mkrmatvn mnYamedM nlaM aWM ,wbk Conepumuantb tivepermemu.4 <br />mepy wan mranekdaml, ume, alamcaHaw. meslanlmy wtaemreonry eumornes aqunreorwrkamnn dawamia mm<trwn. ceramns mustraNne <br />autlraked in milirg firm ttre BuiNdng Olficrel6akva0a'n9auMttrz HunCeranY axaum4anue_lam tlreounar, wl an auMwimd6Y1I'eowrerNlhis pmpatyb <br />perrorm nre wwxrorwNcn ewuaeean i:amce, anar mmav wan me sere conlmoaa taw+eraavamzs#zooa wac <br />///lll TarnrEa�ror 'aluaa aly <br />PERMIT# <br />2 �dta- PW <br />Ovq{/Autnarixea apeM9iPNar IDah t (TRNaM tn2lH9J <br />