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PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETTSUBMITTAL INSTRUCTIONS', Lmellepplpellondsuemlllaleecum.nleb Fe�mll8orvkes�everelMgwmLmPpRa1B1GOCNmekaM4M Fkq�nmp 6m <br />HAISHINGTON CONTACT INFORMATION (F(425-25Z6B101(E) PmmBSomloes@eveleM .gov I M) evereXwakay/p ATI <br />GG "RROJECT:SITE 1 F.b$Ii1AT1q0N <br />PROJECT ADDRESS: U�Je 01.aMP1C. 0Wn CV6 -� WA I� <br />SITE WORK FOR PROJECT TYPE: PTSFRUIDETACHIFID ❑TOWNHOUSE DOUPLE%OADU EIMULTLFAINI LjCOMMERCIAL DINDUSTRIAL <br />W APPLICABLE: ❑ LAND USE PROJECT M (SEPA, PRE-APP, SS, ETC.) <br />IFAPPLICABLE: C]FRANCHISENTILITY COMPANY, ANNUAL BLANKET PERMIT# <br />UTILITYCOMPANY'SNAMEBJOB#: JOB#: <br />" DESCRIPTION OF SITE. WORK ('RIGHT 1 <br />FI LL I N ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />❑FENCE IN ROW FT IN HEIGHT <br />❑DRNEWAYAPRON/CURB CUT ,,/ FTWIDE <br />❑ ASPHALT I CONCRETE PAVING p SF <br />❑RETAINING WALL/ ROCKERY IN RIGHT-OF-WAY _UP <br />❑RETAINING WALL ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />CLEARING/GRADING I FILL/EXCAVATE CY <br />❑ CUTIBORE IN PAVEMENT(PAHALLEL) LF <br />❑ CUTIBORE IN PAVEMENT (NON -PARALLEL) LF <br />❑POLE WORK AERIAL I OVERLASH LF <br />ADDITIONAL DESCRIPTION AS NEEDED: <br />R <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO: <br />OCombinetl Sewer <br />D Sepaalea Form Somer <br />13 Direct DWMarge W Skohomish Rican or PlOat Soum <br />TRIGGERED REQUIREMENTS: <br />❑MR2Only 1341111d ❑MRId <br />QUANTITY OF PROPOSED HARD SURFACES <br />Proposed Roof Ana: Q SF <br />Pmmea Haraacape: D SF P6 <br />IAPNew+Raplacea: 6F S <br />N —f Xpe <br />NS PaI TLtq b 'aA4 OI' e&4l�N <br />e — ✓. R. , Aga „rrr, T <br />AST+INPDR ATIO <br />�.��.."� <br />OWNER I APPLICANT NAME: & H*vk) Win4ANU4 A TN16ff= y <br />OWNER/APP. MAILINGADDRESS: AI 063t OLYM IL LVD I NawB V <br />re oe ,E LV e t?003 <br />/ <br />OWNER I APP. PHONE: 3vy.%31 <br />I I1 <br />,Qf..J1 OWNERIAPP.EMAIL: yyTAaM �p�.o�MR11. <br />'Requlretl lm Work In Public RlgM�IN-Way Up <br />CONTRACTOR NAME: aL 5 E <br />CONTRACTOR ADDRESS: SOMEET /3 2t NE SIL" Sr. <br />'VOW <br />O NVILl.E STATE wit <br />a� <br />CONTRACTOR PHONE: Zf // .L--F CONTRACTOR EMAIL: qb9 )mM liR�S. <br />CONTRACTOR LICENSE D IREQUIREp 6 n A0341" <br />EUI VERETT BUSINESS LICENSE REOUI ON..fNOW <br />kk# <br />PRIMARY CONTACT: ADANNER (APPLICANT ❑CONTRACTOR ❑ OTHER (Architect. EngineeC Etc.) <br />CONTACT NAME: JYTTaA� W�TT4ARA <br />CONTACT PHONE; $e0r;731. SSS( <br />CDNTACT EMAIL: 7 qM H%_tl'WI <br />ACKNOWLEDGEMENT.'/have revHwetllhhapAO'callaaaMcw#/Imfhe le/econal contianabLARRII We erMcare¢L Waa: acnapmsvenfW fhl¢pemW muss <br />aorrrytiy xilhcurrent Tedere( stale• enabce/law iM g2MNg slepamtlt aMy eufhorRea eppmvea wwkaMm aewallcne iherelmm. Dewallmamust flal ba <br />auhhOXmaN wnl/ng fivm the Bui 011lcial fibre heln0 auMarizetl untlnanycbcum Ance.l am the sesrer, orlemaWAeamtl bylhe swmr MlM1lspmperlyb <br />per/OIm IMn AN" a�IIOAI kalWn la maae.aMl¢OmNY wXh the Stela COn4ecbrs Law i&2)RCWarM2g6.2C0AWAC. <br />At kan�—\��a c+lr or ererelt onmlaluaa Dory <br />Q P RM <br />�a Pw 3oc�-O <br />owner nnorlsea Agent slgoawa W #mwaea421I <br />