1730 100TH ST SW 2023-12-29 - Laserfiche WebLink

PIIcUC WORKS PERMIT A&PLICATION CITY OF EVERETT PERMIT SERIWS 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: ) , j2 TT,\,,J A SITE WORK FOR PROJECT TYPE: SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY ❑COMMERCIAL ❑INDUSTRIAL iF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) P((Nl 12, — o -2, 1F APPLICABLE: ❑FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # t,) A A UTILITY COMPANY'S NAME & JOB #: JOB M DESCRIPTION OF SITE WORK I RIGHT-OF-WAY WORK FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: ❑ FENCE IN ROW FT IN HEIGHT M DRIVEWAY APRON / CURB CUT FT WIDE J4 ASPHALT / CONCRETE PAVING SF ❑ RETAINING WALL / ROCKERY IN RIGHT-OF-WAY LF ❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT (� CLEARING I GRADING I FILL / EXCAVATE j i45 CY ❑ CUT/BORE IN PAVEMENT (PARALLEL) LF ❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF ❑ POLE WORK / AERIAL / OVERLASH LF 40DITIONAL DESCRIPTION (AS NEEDED): DRAINAGE MITIGATION QUESTIONS: STORMWA TER DISCHARGES TO: ❑ Combined Sewer R Separated Storm Sewer ❑ Direct Discharge to Snohomish River or Puget Sound TRIGGERED REQUIREMENTS: ❑ MR2 Only J MR1-5 ❑ MR1-9 QUANTITY OF PROPOSED HARD SURFACES: Proposed Roof Area: `3 , Proposed Hardscape: ! , 13 5 SF ITotal New+ Replaced: 4. � ~ � SF CONTACT INFORMATION ' OWNER / APPLICANT NAME: I L N n I, DWNER / APP. MAILING ADDRESS: STREET P. ' . f3o'X2-11 CITY LA / ' _ STATE A ZIP -251b JWNER / APP. PHONE: 4 -- O ° - 5 OWNER / APP. EMAIL: "Required for Work in Public Right -of -Way OONTRACTOR NAME: OfA CONTRACTOR ADDRESS: STREEr. p . j2 O fit CITY '�- „ 5'r v C S STATE ) A ZIP 9 'Zj J 3ONTRACTOR PHONE: Li ? - S p i — 2--1 1 CONTRACTOR EMAIL: CONTRACTOR LICENSE #(REQUIRED): f (.% j'3' G2 EVERETT BUSINESS LICENSE #(REQUIRED): ?RIMARY CONTACT: ❑ OWNER / APPLICANT ❑ CONTRACTOR 19OTHER (Architect, Engineer, Etc.)(�(f�_Z ;ONTACT NAME: eLpe-N Mr CAS IR E. CONTACT PHONE: 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 amply 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 Derform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. .(,Jay, — , Jwne,r/Auth94rized Agent Signature City of Everett Official Use Only PERMIT # 30 212 PW - 7,0 - 0 2,-3 I (Revised 412112022)