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e `! PUBLIC WORKS PERMIT APPLICATION / q E l CITY OF EVERETT PERMIT SERVICES ��VA �/ E R E T T 3200 CEDAR STREET, EVERETT, WA 98201 l�16: Y l P�s WASHINGTON (P)425-257-8810 FAX 425-257-8857 1 (E)everetteps@everettwa.gov g I https://evereftwa.gov/:)ermits _PR ECT SITE INFORMATION gTR PROJECT ADDRESS: 102 SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX IFAPPLICABLE: ❑LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) �ADU, ULTI-FAMILY ❑COMMERCIAL ❑I!VDUS IF APPLICABLE: ❑ FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# UTILITY COMPANY'S NAME&JOB M JOB# ffFENCE DESCRIPTION OF SITE WORK/ RIGHT-OF-WAY WORK LL QUANTITIES OF WORK BELOW,AS APPLICABLE: rDRAINAGE MITIGATION QUESTIONS: :[7 IN ROW FT IN HEIGHT TER DISCHARGES TO: DRIVEWAY APRON/CURB CUT FT WIDE Sewer ASPHALT/CONCRETE PAVINGSFeparated Storm Sewer ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑Direct Discharge to Snohomish River or Puget Sound ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: �I CLEARING/GRADING FILL/ XCAVATE CY ❑MR2 Only ❑ MR1-5 ❑MRI-9 ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF ❑POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced:fYl If ox SF Lac c1�e Oji lD y>° Cork 7,c b. CONTACT INFORMATION OWNER/APPLICANT NAME: iii. OU1GLt� A.Y1 ��Sf001 OWNER/APP. MAILING ADDRESS: STREET IZ Ll Lffi S CITY STATE zip� OWNER/APP.PHO�E: —X�5 '�S J OWNER/APP.EMAIL: --------------- *Required for Work in Public Right-of-Way I Can � L� • CONTRACTOR NAME: ®►'� CONTRACTOR ADDRESS: STREET cITY STATE ZIP Q CONTRACTOR PHONE: a _3 !4 CONTRACTOR EMAIL: F1 GIa CONTRACTOR LICENSE#REQUIRED: 2 / �?etl ( ) "� V C�e__w ' EVERETT BUSINESS LICENSE#(REQUIRED): LGQ qs PRIMARY CONTACT: ❑OWNER /APPLICANT CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: ae-s on CONTACT EMAIL: (� ACKNOWLEDGEMENT.(have reviewed this application and confirm the information contained herei 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.I 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. City of Everett Official Use Only / PERMIT# Own /Au horized gen Signature Date PW '(Revised 1/72019)