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E V E R E T T PUBLIC WORKS REVIEW WORKSHEET <br /> WASHINGTON <br /> PROJECT ADDRESS: 10830 19TH AVE SE STES A & B Permit#: B2205-016 <br /> TENANT: SILVER LAKE DENTAL <br /> DESCRIPTION OF WORK: TI -EXPAND EXTG DENTAL OFFICE INTO ADJACENT OFFICE SPACE <br /> PW Reviewer to select all that apply below: <br /> Utility Permits (Note:Permit Technicians to Create Utility Permit for Sewer, Water, Fire, and Irrigation, as selected below) <br /> SANITARY SEWER: DOMESTIC WATER SERVICE: (Attach Calculation&Cost Est.) <br /> ❑ New Connection to main plus connections to building ❑ New Connection, Size -❑ Per Cost Estimate <br /> ❑ Alteration ❑ Meter Only,Size -❑ Per Cost Estimate <br /> ❑ Repair ❑ W• ater System Development Fee Total:$ <br /> ❑ Cap-off, quantity ❑ Sewer System Development Fee Total:$ <br /> ❑ Reconnection to stub ❑ W• ater Service Line(behind meter), Size <br /> ❑ Backwater Valve ❑ Backflow Prevention(Outside Building): ❑RPBA ❑ DCVA <br /> ® NOT REQUIRED ® NOT REQUIRED <br /> Explanation/Utility Permit# Explanation/Utility Permit# <br /> IRRIGATION SERVICE: (Not Including Cost Estimates) FIRE SERVICE: (Attach Cost Estimate/Request for Reference) <br /> ❑ New Connection, Size ❑ New Connection, Size -❑ Per Cost Estimate <br /> ❑ Meter Only, Size ❑ 3/" Detect Meter Only, Service Size <br /> ❑ Water System Development Fee Total:$ ❑ Backflow Prevention (Outside Building): ❑DCDA <br /> ❑ Backflow Prevention(Outside Building): ❑DCVA ® NOT REQUIRED <br /> ® NOT REQUIRED Explanation/Utility Permit# <br /> Explanation/Utility Permit# <br /> WATER DEPARTMENT COST ESTIMATE NEEDED-(If yes, PW Reviewer to send cost estimate request to Water Department) <br /> ❑ Yes, Quantity , See attached for reference. <br /> • NOT REQUIRED <br /> Plumbing Permits(Note:Permit Technicians to add all items selected below to Plumbing Permit-for items inside building only) <br /> Backflow Prevention(Inside Building): ❑DCVA(for Domestic service) ❑RPBA(for Domestic service) ❑DCDA(for Fire service) <br /> ® NOT REQUIRED <br /> Building Permits (Note:Permit Technicians to add all items selected below to associated Building Permit) <br /> STORMWATER SYSTEM DEVELOPMENT FEES: TRAFFIC MITIGATION FEES: <br /> ❑ YES, ❑ See Attached for calculations/credit OYES,Traffic Mitigation Total: $10356.00 <br /> To be added on PW To be added on ®See Attached for calculations/credit <br /> Quantity charged SF Quantity charged SF ❑ NOT REQUIRED <br /> QTY is❑ Ground only❑ all surfaces QTY is❑ Roof only❑ all surfaces <br /> ® NOT REQUIRED <br /> Additional Checklists: <br /> ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) <br /> ❑ YES—TYPE: ❑ SFR ❑ DUPLEX ❑ADU ❑ INFILL DWELLING ❑ MULTI-FAMILY ❑ COMMERCIAL <br /> ❑ See Attached Letter,2 copies(Permit Techs to issue one copy to applicant with permits, scan one copy to Jeffrey Marks) <br /> ❑ Digital copy attached to permit record, Permit# <br /> ❑ Saved to Address Folder in Development Tech File <br /> ® NOT REQUIRED <br /> FIRE SPRINKLERS REQUIRED? <br /> ❑YES—Type <br /> ® NOT REQUIRED <br /> Reason: <br /> PUBLIC WORKS PERMIT REQUIRED? <br /> ❑YES, Permit#PW <br /> ❑ Stormwater NPDES Tab Completed in TRAKiT ❑ADA Tab Completed in TRAKiT ❑ Inspections Added in TRAKiT <br /> ® NOT REQUIRED <br /> Worksheet Completed By: Date: <br /> Worksheet Completed By: Date: <br /> REVISED 12/22/2021 <br />