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PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETTSUBMITTAL INSTRUCTIONS:Email application&submittal documents to PermilServices@everettwa.gov or drop off at 3200 Cedar Street 2nd Floor Drop Box WASHINGTON CONTACT INFORMATION:(P)425-257-8810 1(E)PermitServices@everettwa.gov 1(W)everettwa.gov/permits RRW ECT.SITE:INFORIUTATION PROJECT ADDRESS: /( Jr/s Sit/ k1A 9'?2_o 3 SITE WORK FOR PROJECT TYPE: •LISFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-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 M JOB M DESCRIPTION:OF`:SITE MORK_t.RrGHT-OF�W'dY 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 SPHALT/CONCRETE PAVING QtO: (T 1—SF ElSeparated Storm Sewer ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑Direct Discharge to Snohomish River or Puget Sound ❑ RETAINING WALL I ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: ❑CLEARING/GRADING/FILL/EXCAVATE CY �roIR2 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 I AERIAL I OVERLASH LF Proposed Hardscape: ( � SF ADDITIONAL DESCRIPTION(AS NEEDED): ITotal New+Replaced: 7 4— SF _T:__op ^Qa_Ar'.j s e 5-reZ...�a K2 S'; s TC.-+► CONT ACT:INFORMATION OWNER/APPLICANT NAME: 12Z t'A Al s'S Ke,*-M ist k--)V t C OWNER/APP. MAILING ADDRESS: STREET CRY STATE ZIP OWNER/APP.PHONE: OWNER/APP. EMAIL: 'Required for Work in Public Right-of-Way CONTRACTOR NAME: O CONTRACTOR ADDRESS: STREET CITY STATE, ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): PRIMARY CONTACT: OWNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect,Engineer, Etc.) CONTACT NAME: CONTACT PHONE: y253413 53//y D244 N1 CONTACT EMAIL: ar/Yt kovtand 4,&,'/ M ACKNOWLEDGEMENT,1 have reviewed this application and confirm the information contained herein is true and correct. Work Yone 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.I 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 Official Use Only PERM 7 Ow r/Ai rite gent Signature Date (Revised 412112022)