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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 FAX 425-257-8857 (E) everetteps@everettwa.gov https://everettwa.gov/permits RROJEGT SITE:INFORMA"�'!ON PROJECT ADDRESS: .5 Rd SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY ITCOMMERCIAL []INDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) • • `-DES�R1�TIiDN�OF$ITE`WORK'fi'RIGiT-QFtWlklf:l�1QRK� :• ": 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 JdASPHALT/CONCRETE PAVING 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: ❑CLEARING/GRADING I FILL I EXCAVATE CY ❑ MR2 Only ❑ 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 coHYrc�r�NFo1i �QH OWNER/APPLICANT NAME: OWNER/APP. MAILING ADDRESS: STREET Z Z l� Gc�5/•,OC? z . f lI el-o- CITY �` STATE C; Z0 ZIP OWNER/APP. PHONE: 5 DC .—�7�.'`j(o w OWNER/APP.EMAIL: �/�'?ct GJ S rGS �G />'C C ASS 'Required for Work in Public Right-of-Way CO �CONTRACTOR NAME: TI � ,14 S 7ki Gt- 'G' G_'��;,,�C_r^G-r-e l"ti/C-: CONTRACTOR ADDRESS: STREET /0 //Z,// U�r r^� lv/� Y 5i`eE Z�=- Se`S_ (-_Vt'i-e TT CITY tail`IQ'- STATE 9,6 "CU ZIP CONTRACTOR PHONE: " 1-°5_ C'J/-- 360c CONTRACTOR EMAIL: 601--1 CONTRACTOR LICENSE#(REQUIRED): , N EVERETT BUSINESS LICENSE#(REQUIRED): 7 Q 0 PRIMARY CONTACT: WNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) CONTAC�AME: CONTACT PHONE: _ ? 2) 0' S FI-A--S CONTACT EMAIL: J71a e_ _ -' 4 ACKNOWLEDGEMENT.,I have reviewed this application and confirm the information contained herein 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 tfr#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 wh,i application is made,and/comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# PW Owner/Aut z d Agent Signature Date (Revised 4/15/2019)