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1 <br /> PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1 (E)eve rettepst§eve rettwa.gov I hUpsWeverettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS:Madera lane Part of 4900-5000 block of 23rd Ave. W and Granada HOA <br /> SITE WORK FOR PROJECT TYPE: ✓❑SFR-DETACHED ❑TOWNHOUSE [--]DUPLEX ❑ADU ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <br /> FILL_IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> ❑FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE L7 Combined Sewer <br /> R]ASPHALT/CONCRETE PAVING 6200 SF ❑Separated Storm Sewer <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF (-) Direct Discharge to Snohomish River or Puget Sound <br /> LJ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> ❑CLEARING/GRADING/FILL/EXCAVATE N/A CY ❑ MR2 Only ❑ MR1-5 ❑ MR1-9 <br /> L1 CUT/BORE IN PAVEMENT(PARALLEL) N/A LF QUANTITY OF PROPOSED HARD SURFACE'S: <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF <br /> I-1 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> Asphalt overlay of exising paved lane (Madera Lane) <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME:Bob Kelly for Al Gipson, Granada HOA President <br /> OWNER/APP. MAILING ADDRESS: STREET5009 23rd Ave. W <br /> c" Everett STATE WA Z!P 98203 <br /> OWNER/APP. PHONE:425-359-0912 OWNER/APP.EMAIL:quadkell s9hotmaii.com <br /> 'Required for Work In Public Right-of-Way <br /> CONTRACTOR NAME: North Shore Paving <br /> CONTRACTOR ADDRESS: STnEET P.O. BOX 516 <br /> crry Woodinville STATe WA ZIP 98072 <br /> CONTRACTOR PHONE:425-488-7725 1 CONTRACTOR EMAIL:northshore avis .net V <br /> CONTRACTOR LICENSE#(REQUIRED):NORTH PI 131 N4 EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: (V1 OWNER /APPLICANT ❑ CONTRACTOR ❑OTHER (Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE:425.359.0912 <br /> Bob Kelly CONTACT EMAIL: uadkell s@hotmail.com <br /> ACKNOWLEDGEMENT,f 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 federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviatlons must first be <br /> authorized In writing from the Building Official before being authorized under any circumstance.I am the owner,or 1 am authorized by the owner of this property to <br /> perform the work for which application is made,and I comply with The State Contractors Law 18.27 RCW and 296,200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> Nov. 9 2021 P W /1 - JI) <br /> Owner/Authorized Agent Signature Date (Revised 1/72019) <br />