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® PUBLIC WORKS PERMIT APPMATION <br />L: CITY OF EVERETT PERMIT SERVICES <br />EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br />lol eoq.on.aAtn I PA%d9F95]-885T 1(E) evereReoe(fmXefetUmI.goV l lifts111eveledwri gov/pennit6 <br />WASHINUTON <br />f A. P+Axx <br />PROJECTADDRESS: UG e. OYI I/CYC <br />BITE WORK FOR PROJECT TYPE: OSFR-CEUICHE) EITGWNHOUSE OOUPLEX QACU pMULJj+Rw$LY OCOMMERCNL OINEUSTRIAL <br />IFAPPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP. SS, ETC.) <br />y <br />DRAINAGE MITIGATION QUESTIONS: <br />FILL IN ALL QUANTITIES OF WORK BE LOW, AS APPLICABLE: <br />STORMWATER DISCHARGES TO: <br />�FENCEIN ROW �� FT IN HEIGHT <br />❑DRNEWAYAPRON/CURB CUT FTWIDE <br />❑CamtimaJ Smear <br />�y <br />g ASPHRTT f CONCRETE PAVING Ir B- SF <br />❑ Sepsmlei Seem Smear <br />❑RETAINING WALL ROCKERY IN RIGHT-OF-WAY __LF <br />❑DIreN Discharge m Saohormsh Ram or Paust Sound <br />CI RETAINING WALL/ ROCKERY OVER 4FT IN HEIGHT FTTMALHEIGHT <br />TRIGGERED REQUIREMENTS: <br />❑ CLEARING I GRADING I FILL/EXCAVATE CY <br />❑MR20ny ❑MRtS ®MR1-9 <br />❑ CUTIBORE IN PAVEMENT (PARALLEL) LF <br />QUANTITY OF PROPOSED HARD SURFACES. <br />❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br />PmpowJ RomAree SE <br />❑POLE WORK/ AERIAL I OVERLASH LF <br />Pmpescl HmJmrrpe: SF <br />ADDITIONAL DESCRIPTION JAS NEEDED): <br />TOlal New+Re eDal 6F <br />K <br />L <br />_.ev' :: <br />OWNER/APPLICANT NAME: 4-61 k�ffz) ot W' <br />OWNER/APP. MAILINOADDRESS: mmiv 4241 <br />5 ue re <br />SPRE <br />OWNER I APP. PHONE: - OWNERIAPP.EMAIL: <br />'Reaelrea for Work In PuD is R om-WW <br />CONTRACTOR NAME: <br />CONTRACTORADDRESS: <br />GIN <br />CONTRACTORPHONE: <br />CONTRACTOREMAIL: <br />CONTRACTOR LICENSE #(REQUIRED) : EVEREU BRININESS LICENSE CREUTFILD): <br />alZr <br />PRIMARYCONTACT: OWNER/APPLICANT ❑CONTRACTOR ❑ OTHER(Architad, Engineer, Elc.) <br />FT NAME: <br />CONTACT PHONE: <br />D <br />CONTACT EMAIL: <br />r <br />R <br />AM <br />/ <br />1 <br />AdKNOMEDGEMENT. I have PhomWo SS elloWneen eMwnM1r"'ne.vnwnawn amemom nwmnranue my �w,=m .n,.e a-w............... <br />Lwnpy WM ewrenl (mere{ Were and mmDoW. Me ryeNing Ora DarmJ may a mmum; approved M&and nooWrelMa MCMmm Cevaffelm must Lust Im <br />autnerRark wrn➢&mh #la Bra tln90#X RUmmm being auMmhetl unmeranydmumelaraca. l am Iha OWner. w1 am axlllwimmhy the rx~0fthis ImilmY 0 <br />p Me Fare In, which aWflca'ienRmerle, and l cm4PY WiM llm Stale G010ecl43 Lee !&DRCU`mm29B' WAG <br />CNY Oiflrerep QYNeI fha OMY <br />EP RMIT# <br />r"" 3 �i aui3 Pw <br />Ow lOtlze Age 1 t re aIa (ftaviseN4HY3019J <br />