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PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETTSUBMITTAL INSTRUCTIONS'. Parma lbn A suLmNa l Eoeomenk a PmmlSmYes4eve,elnre.9ov o,C,op offal mnn Ceda. 31,eel inn Elms Drop Box <br />WASHINGTON CONTACT INFORMATION: IP) 425-257E5101IS) PeragReNlceageoemllw"go, l M9 evcm¢rvago,me mils <br />CLE4`T'SITE'1 P.ORMATION -` rdP <br />PROJECTADDRESS: ISofaab ST. 4U.T a/ LTT IA)A ° `(- <br />SITE WORK FOR PROJECT TYPE: OBFWDETACHED OTOWNHOUSE ODUPLEX OADU OMUL71 FAMILY OCOMMERCNL OINDUSTRIPL <br />IF APPLICABLE: ❑ LAND USE PROTECT N (SEPA, PRE-APP, SS, ETC. <br />IF APPLICABLE: OFRANCHISENTILITY COMPANY, ANNUAL BLANKET PERMIT# <br />UTILITY COMPANY'S NAME B JOB A JOB#: <br />.rOEBCRIPTION OF -SITE WORK I A 6NT-OP.WT <br />R -:. ` <br />FILL IN ALL QUANTRIES OF WORK BELOW, AS APPLICABLE: <br />❑FENCE IN ROW FT IN HEIGHT <br />❑DRIVEWAYAPRONICURBCUT "WIDE <br />(RASPHALT/ CONCRETE PAVING Isn 777 SF <br />❑RETAINING WALL ROCKERY IN RIGHT-0FWAY _LF <br />❑ RETAINING WALL I ROCKERY OVER 4FT IN HEIGHT FTTOTALHEIGHT <br />❑ CLEARING I GRADING/FILL/EXCAVATE CY <br />❑ CUT/BORE IN PAVEMENT (PARALLEL) LF <br />O CUTIBORE IN PAVEMENT (NONPARALLEL) LF <br />❑POLE WORK/ AERIAL I OVERLASH LF <br />ADDRIONAL DESCRIPTION AB NEEDED: <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO: <br />0Combined Sexy <br />O SEDalaled Slam, Serer <br />Dined Cb:chwga to SlxYnenlsh River or Pagel Sound <br />TRIGGERED REQUIREMENTS' <br />13MR20o 131fiR45 13MI <br />QUANTITY OF PROPOSED HARD SURFACES: <br />Plcpoal Ford Frew BE <br />Pmpoaea Hardral SF <br />icUl rvew. Repkcea: sF <br />Le ve <br />r,. g :r CONTACT INI ORMATION. + " <br />OWNER I APPLICANT NAME: QuA/J HU NH <br />OWNER I APP. MAILING ADDRESS: 6 ZADD $ , SW. <br />9820 <br />v)t LTT CITY WA an <br />OWNER/APP. PHONE: q2Y-{$%0- 3,9 Ua <br />OWNERIAPP. EMAIL: G2 �I0.VW49i C2C C�CO M <br />'ReOVYed for Work In PYWc RIgM1bFWay <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET <br />Of MATE 21P <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LICENSE #(REQUIRED): <br />EVERETT BUSINESS LICENSE MREQUIRED):. <br />PRIMARY CONTACT: DOWNER/APPLICANT ❑CONTRACTOR ❑OTHER(Architect, Engineer, ER,) <br />CONTACT NAME: <br />Q IAAN H fV{t <br />CONTACT PHONE: gS - QTO - 3909 <br />CONTACT EMAIL: Q 'UL <br />ACKNOWLEDGEMENT: I Fare reNawedlMa epPlkaNan and coNbm the lMw kncmit ed Mre kl mdw LWah One puwuflMrolMe PemW mue( <br />conk* MIM1 clweM haws( sade, aMbcallaw. Thu granllrlg dapemuY aMy aWlwn'na spprowa NM aMrw aerialMna IM1erelrcm. Cewluru musllnal be <br />aVMMma M wMh®l the Mardeng Call balbeing aulMlzeaVmM any cNcummlance.l em Mecwmr, Or l am adhaYred by ME wmw of Mb pq>Myk <br />parknn IM1a xwk /d wM1hM1 app vMI is made, andlcmplyx#h NOW MGM Cnnbackal Law IB2T RCW amf2M OMAA WAG <br />GYyol Everell Olfrcial UsaM <br />DU7 zPz3 PW a3 O� <br />OwnedAUMPrIaad Aaam BlenB.W Oal tR.Wna A^[IR02!) <br />cta3-�ti96 <br />