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PUBLIC WORKS PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https:Heverettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: 8531 Evergreen Way <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU []MULTI -FAMILY ❑✓ COMMERCIAL ❑INDUSTRIAL <br />IF APPLICABLE: Z✓ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) TBD <br />EPPLICABLE: ❑ FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT# <br />UTILITY COMPANY'S NAME & JOB M JOB # <br />DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK <br />FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />❑ FENCE IN ROW FT IN HEIGHT <br />❑ DRIVEWAY APRON / CURB CUT FT WIDE <br />❑✓ ASPHALT / CONCRETE PAVING SF <br />❑ RETAINING WALL / ROCKERY IN RIGHT-OF-WAY LF <br />❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />✓❑ CLEARING / GRADING I FILL / EXCAVATE CY <br />❑✓ CUT/BORE IN PAVEMENT (PARALLEL) LF <br />❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) LF <br />❑ POLE WORK / AERIAL I OVERLASH LF <br />ADDITIONAL DESCRIPTION (AS NEEDED): <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO: <br />❑ Combined Sewer <br />❑✓ Separated Storm Sewer <br />❑ Direct Discharge to Snohomish River or Puget Sound <br />TRIGGERED REQUIREMENTS: <br />❑ MR2 Only ❑ MR1-5 ❑ MR1-9 <br />QUANTITY OF PROPOSED HARD SURFACES: <br />Proposed Roof Area: 4,359 SF <br />Proposed Hardscape:4'--57- +69 PJ SF-r!" <br />Total New+ Replaced:ZAG+- `) 251 srr. . <br />SITE WORK CONSISTS OF PARTIAL SITE CLEARING AND RE -GRADING, NEW UTILITY SERVICE <br />RUNS AND CONNECTION, EXPANDED PARKING, NEW BUILDING FOUNDATION, LANDSCAPE <br />AND IRRIGATING, AND SURFACE WATER RUNOFF CONTROL. <br />CONTACT INFORMATION <br />OWNER I APPLICANT NAME: Community Health Center of Snohomish County <br />OWNER / APP. MAILING ADDRESS: STREET 8609 Evergreen Way <br />c,TY Everett STATE WA Z,, 98208 <br />OWNER / APP. PHONE: 425.789.3800 <br />OWNER / APP. EMAIL: dkapetanov@chcsno.org <br />'Required for Work in Public Right -of -Way <br />CONTRACTOR NAME: Aldrich & Associates, INC. <br />CONTRACTOR ADDRESS: STREET 810 240 St. SE <br />c,n Bothell STATE WA ZIP 98021 <br />CONTRACTOR PHONE:425.483.1919 <br />CONTRACTOR EMAIL: mdaumen@aldrich-assoc.com <br />CONTRACTOR LICENSE #(REQUIRED): ALDRIA'202RU <br />EVERETT BUSINESS LICENSE #(REQUIRED): 39375 <br />PRIMARY CONTACT: ❑ OWNER / APPLICANT ❑ CONTRACTOR ❑✓ OTHER (Architect, Engineer, Etc.) Architect <br />CONTACT NAME: <br />Janet L . M o n d a <br />CONTACT PHONE: 425.823.2244 <br />CONTACT EMAIL: janet@awerks.com Cc: ryan@awerks.com (Ryan O. Ivie) <br />ACKNOWLEDGEMENT: I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must <br />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 <br />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 <br />perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br />02/16/2023 <br />p.p. Ryan O. Ivie, Janet L. Monda <br />Owner/Authorized Agent Signature Date <br />City of Everett Official Use Only <br />PERMIT # <br />PW 2,,302' Ol <br />(Revised 1172019) <br />