517 95TH PL SW 2023-11-29 - Laserfiche WebLink

PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EV E R E T T SUBMITTAL INSTRUCTIONS: Email application 1£ submittal documents to PermitServices@everettwa.gov or drop off at 3200 Cedar Street 2nd Floor Drop Box WASHINGTON CONTACT INFORMATION: (P) 425-257-8810 1 (E) PermitServices@everettwa.gov I (W) everettwa.gov/permits PROJECT SITE: INFORMATION PROJECT ADDRESS; 7 i1 SITE WORK FOR PROJECT TYPE: FR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY ❑COMMERCIAL ❑INDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # UTILITY COMPANY'S NAME & JOB M JOB M DESCRIPTION OF SITE WORK/ RIGHT-OP*AY WORK FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: ❑ FENCE IN ROW FT IN HEIGHT ❑ DRIVEWAY APRON / CURB CUT FT WIDE �0 ASPALT / CONCRETE PAVING) q f-) SF ❑ RETAI-9 G WALL / ROCKERY IN RIGHT-OF-WAY LF ❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT ❑ CLEARING / GRADING / FILL / EXCAVATE CY ❑ CUT/BORE IN PAVEMENT (PARALLEL) LF ❑ CUTIBORE IN PAVEMENT (NON -PARALLEL) LF ❑ POLE WORK i AERIAL / OVERLASH LF ADDITIONAL DESCRIPTION (AS NEEDED): ITotal DRAINAGE MITIGATION QUESTIONS: STORMWA TER DISCHARGES TO: ❑ Combined Sewer ❑ Separated Storm Sewer ❑ Direct Discharge to Snohomish River or Puget Sound TRIGGERED REQUIREMENTS: ❑ MR2 Only ❑ MR1-5 ❑ MRi-9 QUANTITY OF PROPOSED HARD SURFACES: Proposed Roof Area: SF Proposed Hardscape: SF New+ Replaced: SF bril/k t p� CONTACT INFORMATION OWNER / APPLICANT NAME: OWNER / APP. MAILING ADDRESS: STREET�ftkL CITY k STATE (x ZIP OWNER / APP. PHONE: OWNER / APP. EMAIL: 'Required for Work In Public Right -of -Way CONTRACTOR NAME: D (, CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE #(REQUIRED): EVERETT BUSINESS LICENSE #(REQUIRED): PRIMARY CONTACT: © OWNER /APPLICANT ❑ CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) CONTACT NAME: DdN T�0� CONTACT PHONE: _ 7CP CONTACT EMAIL: - ^ ACKNOWLEDGEMENT. I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with current federal, state, and local law. The granting of a permit only authorizes approved work and no deviations therefrom. Deviations must first be authorized in writing 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 perform the work for which application is made, and t comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only IPERMIT#,, PW 3D q -in-inp o OwnerlAuthorized Agent Signature V Oate (Revised 412112022)