9610 19TH AVE SE 2024-03-05 - Laserfiche WebLink

PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETTSUBMITTAL 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: 961 0 1 9th Ave. S.E. , Everett, WA, 98208 SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY RCOMMERCIAL ❑INDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT # 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 ❑ DRIVEWAY APRON / CURB CUT FT WIDE ❑ ASPHALT / CONCRETE PAVING SF ❑ RETAINING 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 ❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF ❑ POLE WORK / AERIAL / OVERLASH LF ADDITIONAL 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 ❑ MR1-5 ❑ MR1-9 QUANTITY OF PROPOSED HARD SURFACES: Proposed Roof Area: SF Proposed Hardscape: SF ITotal New+ Replaced: SF Install 1 17X30 vault as pull box. Install 1 4" conduit no more than 36" deep Approx. 25' hand trenched for fiber upgrade to cell site on private property. No staging of material and backfilling with excavated dirt. No ROW work. CONTACT INFORMATION OWNER IAPPLICANT NAME:Actualize LLC OWNER/APP. MAILING ADDRESS: STREET#456 160 Gilman Blvd CITY Issaauaah STATE WA z,, 98027 OWNER/APP. PHONE:206-372-0516 1OWNER/APP. EMAIL: sarah.hull(w^actualize-Ilc.com `Required for Work in Public Right -of -Way CONTRACTOR NAME: Silver IT ech CONTRACTOR ADDRESS: STIEET2561 152nd Ave NE CITY Redmond STATE WA zip 98052 CONTRACTOR PHONE:206-375-0252 I CONTRACTOR EMAIL: brad. iacobsonCd)silvertech.net CONTRACTOR LICENSE #(REQUIRED): S I LVE L*792RB EVERETT BUSINESS LICENSE #(REQUIRED): TB D PRIMARY CONTACT: R OWNER / APPLICANT ❑ CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) CONTACT NAME: 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 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. 1 am the owner, or I am authorized by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. Sarah Hull 11 /9/22 Owner/Authorized Agent Signature Date City of Everett Official Use Only PERMIT # PW (Revised 412112022)