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PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EV E R E T T SUBMITTAL INSTRUCTIONS:Ernall applicallon&submittal documents to Parm]tServicos@everettwa.gov of drop off at 3200 Cedar Street 2nd Floor Drop F30X <br /> WASHINGTON CONTACT INFORMATION:(P)425-257-88101(E)PorrnitServIceS@everettwa,gov I(W)everettwa.gov/permits <br /> 1...:4-0, <br /> 'SF7777777 -7777 7771&', <br /> 77771 <br /> . 1 _N 15"-77 _7 77T 777 <br /> PROJECT ADDRESS: e,-� Yii ev le— <br /> SITE WORK FOR PROJECT TYPE; 0 SFR-DETACHED 13TOWNHOUSE 11DUPLEx DADU 6ULTI-FAMILY 13COMMERCIAL DINDUSTRIAL <br /> IF APPLICABLE: DLAND USE PROJECT#(SEPA,PRE RPP,SS, ETC.) <br /> IF APPLICABLE: OFRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB 0: _JOBM <br /> T i FRb ti-Wd JOW41% 0AWAY <br /> 777,777 7' 75 <br /> 7 <br /> Fad <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> XFENCE IN ROW FT IN HEIGHT STORMINATER DISCHARGES TO: <br /> El DRIVEWAY APRON/CURB CUT FT WIDE 0 Combined Sewer <br /> XASPHALT I CONCRETE PAVING _SF C3 Separated Storm Sewer <br /> 1:1 RETAINING WALL ir ROCKERY IN RIGHT-OF-WAY LF 13 Direct Discharge to Snohomish River or Puget Bound <br /> 11 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> El CLEARING I GRADING/FILL/EXCAVATE CY C3 MR2 Only E3 MRI-5 13 MRI-9 <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTIFY OF PROPOSED HARD SURFACES. <br /> El CUTIBORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area:.. 8F <br /> El POLE WORK/AERIAL I OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION AS NEEDED): lTotal New+Replaced:_,,_—__ 8F <br /> Create concrete parking slab 10' in length x Twide, on NW Corner of house. <br /> Will install Utall cedar fence at property line to screen parking slab from <br /> neighboring property. (per phone Conversation 1211512022 TH with ice) <br /> ­77-777777 7 <br /> T <br /> AT <br /> OWNER I APPLICANT NAME: <br /> OWNER/APP, MAILING ADDRESS: STREET 7. Ab- >. <br /> cffy (4 r" STATE LI.-Id— ZIP <br /> OWNER I APP.PHONE: 2 Q& 2;;!7- [OWNER 1 APP.EMAIL: <br /> 'Requited for Work In Public Right-of-Way <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CRY STATE ZIP <br /> CONTRACTOR PHONE: 1CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED)- IEVERETT BUSINESS LICENSE#(REQUIRED):.. <br /> PRIMARY CONTACT: 13 OWNER I APPLICANT 11 CONTRACTOR 13 OTHER(Architect,Engineer,Etc,) <br /> CONTACT NAME: ICONTACT PHONE: <br /> ICONTACT EMAIL: <br /> ACKNOWLEDGEMENT•/have reviewed this application and confirm the Information contained herein Is true and correct.Work done pursuant to this permit must <br /> comply with current federat,state,and local law.The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be <br /> authorized in wriling from the Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to <br /> perform the wor ch application is mad,and/comply with the State Contractors Law f6.27 RCW and 296.200A WAC, <br /> City of Everett Official Use Only <br /> �7& <br /> PER # <br /> C'-' U::: -- )3 IPW <br /> Ow"r AhorIzed Agent Signature Date (Revised 4121&22) <br />