1728 100TH ST SW 2024-01-04 - Laserfiche WebLink

PIIQLIC WORKS PERMIT AAPLICATION CITY OF EVERETT PERMIT SERIFES EV E R E T T SUBMITTAL INSTRUCTIONS: Email application & 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: j E j2 T WA 982-04 SITE WORK FOR PROJECT TYPE: SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY ❑COMMERCIAL ❑INDUSTRIAL iF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) ON i 22 o 2. 7� SF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # ram) A % UTILITY COMPANY'S NAME & JOB #: JOB #: DESCRIPTION OF SITE WORK./ RIGHT-OF-WAY WORK FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: ❑ FENCE IN ROW FT IN HEIGHT IR DRIVEWAY APRON I CURB CUT 0 FT WIDE 0 ASPHALT / CONCRETE PAVING " j 35 SF El RETAINING WALL / ROCKERY IN RIGHT-OF-WAY LF ❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT CLEARING I GRADING / FILL / EXCAVATE j +_j7 CY ❑ CUT/BORE IN PAVEMENT (PARALLEL) LF ❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF ❑ POLE WORK / AERIAL / OVERLASH LF NDDITIONAL DESCRIPTION (AS NEEDED): DRAINAGE MITIGATION QUESTIONS: STORMWA TER DISCHARGES TO: ❑ Combined Sewer � Separated Storm Sewer ❑ Direct Discharge to Snohomish River or Puget Sound TRIGGERED REQUIREMENTS: ❑ MR2 Only JR MR1-5 ❑ MR1-9 QUANTITY OF PROPOSED HARD SURFACES: Proposed Roof Area: 'I ? SF Proposed Hardscape: ! 13 5 SF Total New+ Replaced: `f. 7 ` L SF CONTACT INFORMATION DWNER / APPLICANT NAME: AMA DWNER / APP. MAILING ADDRESS: STREET . (jO' ' 2-2-1 CITY (_A / 5 " NSTATE . A ZIP 25b DWNER / APP. PHONE: tj — .0 ' - C7 OWNER / APP. EMAIL: �,AVILIL)P `' (g)MAX CC Required for Work in Public Right -of -Way DONTRACTOR NAME: 01PA DONTRACTOR ADDRESS: STREET.�'.1 2 `� CITY .S;T � Y t"s STATE I /� � „ ZIP q -25 1 'ONTRACTORPHONE: L47 15 -S(, 6 --Z"I CONTRACTOR EMAIL: AQlZU(,r''� F/Ji( (inM CONTRACTOR LICENSE #(REQUIRED); jn f (� EVERETT BUSINESS LICENSE #(REQUIRED): 3RIMARY CONTACT: ❑ OWNER / APPLICANT ❑ CONTRACTOR OTHER (Architect, Engineer, Etc.) 6N461 ''%j CONTACT NAME: w M (AM, - E • CONTACT PHONE: CONTACT EMAIL: r� /� - t\I [�) [),I -, °' "�? t'T U 14 ACKNOWLEDGEMENT- I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must ;:omply 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 .)erform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. Agent Signature City of Everett Official Use Only PERMIT # 12 PW 27_V - Dz3 I (Revised 412112022)