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PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT RITE INFORMATION PROJECT ADDRESS: 102.0 A 0 a v-erICIF LC8 /q D SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU,,(OULTI-FAMILY ❑COMMERCIAL []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: DRAINAGE MITIGATION QUESTIONS: ❑FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: DRIVEWAY APRON/CURB CUT FT WIDE ❑ Combined Sewer ASPHALT/CONCRETE PAVING `'y SF ❑Separated 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: FILL/ CLEARING/GRADING XCAVATE 141 i��'��(�'Y ❑MR2 Only CI MR1-5 ❑ MR1-9 ❑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): ITotal New+Replaced: SF x qS -b 8' IIAIC4P /3S-D �23S C '1 cir to l0 644 i'll w CntIjUd CONTACT INFORMATION OWNER/APPLICANT NAME: Aiad^ OUG�L,11ve dl• ' .Y7 OWNER/APP. MAILING ADDRESS: STREET I Z—1 Lf S 4skAwa== &kl -G` /(po�l CITY STATE UAK- ZIP' v1� OWNER/APP.PHONE: �cS3-' S � ' OWNER/APP.EMAIL: 4A& ��h �3F.lCOr' "Required for Work in Public Right-of-Way Q ®� CONTRACTOR NAME: jew-) 6Pffffa&hn,.,ez (r-�, CONTRACTOR ADDRESS: STREET CITY STATE ZIP O CONTRACTOR PHONE: a —� Ll CONTRACTOR EMAIL: ►gGla arr1GII'1Gt L�_M6.f=x�y CONTRACTOR LICENSE#(REQUIRED): 1 VIC V Le_ -- I EVERETT BUSINESS LICENSE#(REQUIRED): loO %S PRIMARY CONTACT: ❑OWNER /APPLICANT CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: � ACKNOWLEDGEMENT.I have reviewed this application and confirm the information contained herei s 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.t 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 Oficial Use Only PERMIT# a 4Z , It -e Ipw Own /Au horized hgent Signature Date (Revised 1172019)