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Intake & Approval Sheet (FOR PERMIT STAFF ONLY) PERMIT # <br />BUILDING <br />Intake OK by: Date: <br />Intake Comments: <br />❑ Make this a "W" Permit ❑ SRC Required (Pre-Insp) <br />BIdg/Tl/Adds/Rem Size <br />p Zt*y ) <br />GaragelAccessory Struct. Size <br />�- <br />Number of Stories <br />_ <br />Basement <br />No ❑Yes , Fin / Unfin <br />Type of Construction <br />Occupancy Group <br />Occupancy Loadii <br />Cert. of Occpuancy Required? <br />[]No MYes []Shell Only <br />Code Year <br />112021 K12018 112015 <br />Fire Sprinklers: []Update Existing ❑New System NNot Req'd <br />Reason Sprinklers Required: <br />Fire Alarm: ❑Update Existing ❑New System V Not Req'd <br />Reason Fire Alarm Required: <br />ROW 64.55 MF worksheet req'd for permit? []Yes No <br />Add1 RCW. 64.55 does required prior to final? ❑Yes No <br />VALUATION CALCULATION: Total $ `7 2 a-L? <br />�*,,c t--�7o I �0 <br />�iN )C 66 <br />Additional Notes: �f '7` LAk V PS <br />f <br />Approved By: Date: 41-1 <br />u <br />FIRE DEPARTMENT <br />Separate I Deferred Submittals Required: <br />❑Fire Sprinklers ❑Fire Alarm ❑Other: <br />Additional Notes: <br />Fire Dept. Fees: <br />❑ Review of As -Built Plans - NO FIRE FEE <br />t❑ Minimal or No Fire Scope - NO FIRE FEE <br />V Review / Inspection Scope - ADD FIRE FEE <br />Approved By: Date: — <br />ELECTRICALIPLUMBING <br />Additional Notes: <br />Approved By: Date: <br />PLANNING <br />Intake OK by: Assign To: Date: <br />Intake Comments: <br />Zone <br />Overlay/Agreement <br />Nonresidential Use <br />Residential Use <br />Proposed No, of Dwelling Units: <br />2 <br />Total No. of Dwelling Units: <br />Planning]Landscape Inspection Required before Final? El es []No <br />"in Lieu" Fee: Type: Amount $ <br />School Impact Fee: Total $ <br />Calculated: ; / 2 Credit: <br />❑Everett School Dist QAUkllteo School Dist <br />Park Impact Fees for permits applied for after 111/2022:_V3/� 6 4 l <br />Park Impact Fee Total $ ('pl�j (net due after credit for exist4uses) <br />Fee Schedule Used For Calculation (Year): 6?Rz <br />Additional Notes: <br />f � /z � <br />Approved By: Date: <br />©Gb <br />PUBLIC WORKS <br />Intake OK by: Date: - <br />,.....,..... ............. <br />..., ,., <br />Intake Comments: PW Revle►v & Worksheet Neededif: <br />[]Sys Dev Eval : <br />❑Water ❑Sewer ❑Storm <br />t[]Traffic Mitigation Eval <br />tGSite Wcrk/Drainage (shownitriggered) <br />ClAddress Letter <br />IE]Backflow Prevention for high hazard: <br />j(dental, medical, animals, mortuary, <br />,hospital, supportive housing) <br />I <br />This Permit is Approved by Public Works <br />See PW Review Worksheet and associated attached items <br />A Separate PW Permit is Required (Permit #: PW'Z 2 -019 ) <br />AND M Is fully digital <br />❑ Is located in this folder <br />❑ Is in a Separate Green Folder Qoin with this folderfor permit Issuance) <br />❑ Will be issued separately (Separate Green Folder, PW issued ahead of Bldg) <br />❑ Public Works has. no scope on this permit--- PW Not Required <br />Additional Notes: <br />Completed By: j Date:2VL21 <br />'_j Q <br />