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PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 f FAX 425-257-8857 1 (E)everetteps@everetlwa,gov I littps://overettwa.gov/perinits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 810C.A o -rr <br /> SITE WORK FOR PROJECT TYPE: 2•DETACHf_ OWNriOUSr UI'Le DU UI-TI.FAMILY oMMERCIA► DUSYRIAL <br /> IF APPLICABLE: AND USE PROJECT 11(SEPA, PRE-APP, SS, ETC.) wy <br /> IF APPLICABLE: [—]=RANCI-IISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT <br /> UTILITY COMPANY'S NAME$JOB#: JOB# <br /> DESCRIPTION OF SITE WORK 1 RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> ENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> RIVEWAY APRON/CURB CUT FT WIDE ombined Sewer <br /> PHALT I CONCRETE PAVING <br /> r±}QS SF 3aparated Slorm Sower <br /> ETAINING WALT_1 ROCKERY IN RIGHT-OF-WAY LF irect Discharge to Snotrornish River or Puget Sound <br /> ETAINING WALL I ROCKERY OVER 4FT IN HEIGHT/, FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> LEARING I GRADING I FILL I EXCAVATE /(//� CY R2 Only RI-5 �hRI-9 <br /> .UT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> ,UT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area:,__........_--.............-..-...--....._._.Sf" <br /> 'OLE WORK/AERIAL I OVERLASH LF Proposed I lardseapn:._... ....................._.......... .......... <br /> ADDITIONAL DESCRIPTION AS NEEDED): lTotal New 4 Re placed: SF <br /> S l v✓�rl� x /:5 1 <br /> CONTACT INFORMATION <br /> OWNER I APPLICANT NAME: -Be-r---r fz�)Y A L GrIL +A re-S i C�<!.w <br /> OWNER I APP. MAILING ADDRESS: SIRLP 6262- :,3 E dAve. <br /> city E-V8r-c--'t star( wA, zip 215F26 <br /> OWNER/APP. PHONE: JOWNER I APP.EMAIL: <br /> 'Required for Work in Public Right-of-Way <br /> ``�� <br /> CONTRACTOR NAME: Di'!f7 dry 0.0 ;I-) <br /> CONTRACTOR ADDRESS: SrrrcLT ,vY_ / , —f�e <br /> 01V e STAI[ W14 ZIP ZY 6 <br /> • fJ- <br /> CONTRACTOR PHONE: Sig —7 7,ZS-- CONTRACTO�R/EMAIL: !'JCS/"')'h$h , ! > <br /> CONTRACTOR LICENSE#(12EQUIRED): Q 7' f 3l /V EVERETT BUSINESS LICENSE#(RE=QUIRED): <br /> PRIMARY CONTACT: INNER /APPLICANT CONTRACTOR )THER(Archltacl, Engineer,Etc.) <br /> CONTACT NAME: ICONTACT PHONE: 4/aS= d / �6 2 <br /> CONTACT EMAIL: be-vle— . v- V v) <br /> ACKNOWLEDGEMENT.-I!rave roviowod this applicntloo and confirm tho Information contalnod hot'oin is Into amt corroct. Work done pursuant to this polmit must <br /> comply wish current fodoral,state,and local low. Tho yrarttiog of a pormil only aulhor'izos approved work and no doviations thorofrom.Doviallons must first be <br /> authorized in writing from the Building Official boforo boing aulhorizod 1111(for any circumstance.I am tho owner,or I am authorized by lho owrnor of this property to <br /> perform the work for which applicallon Is ma(fo,and 1 comply with tho Stale Contractors Law 18.27 RCW and 298.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT 1t <br /> Al <br /> IPW Z Z 0 5 - 0-0 <br /> Owner/Authorized Agent Signa re Date (Revised 1172019) <br />