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Intake & Approval Sheet • (FOR PERMIT STAFF ONLY) • PERMIT# d`—>0 C <br /> BUILDING PLANNING <br /> Intake OK by: Date: Intake OK by: Assign To: Date: <br /> Intake Comments: Intake Comments: <br /> Zone <br /> ❑ Make this a'NW-Permit ❑ SRC Required (Pre-Insp) Overlay/Agreement <br /> Bldg/TI/Addnittem Sim 2 403 ` Nonresidential Use <br /> Garage/Accessory Struct.Size Residential Use <br /> Number of Stories � Proposed No.of Dwelling Units: <br /> 5 <br /> Basement niNo ❑Yes , Fin/Unfin Total No. of Dwelling Units: <br /> Type of Construction , i'ea: Planning/Landscape Inspection Required before Final? ❑Yes ❑No <br /> Occupancy Group "In Lieu"Fee:Type: Amount$ <br /> Occupancy Load School Impact Fee: Total $ <br /> Cert.of Occpuancy Required? Qblo ❑Yes ❑Shell Only Calculated: Credit: <br /> Code Year ❑2021 .02018 02015 ❑Everett School Dist ❑Mukilteo School Dist <br /> Fire Sprinklers: ❑Update Existing ['New System'JNot Req'd Park Impact Fees for permits applied for after 1/1/2022: <br /> Reason Sprinklers Required: Park Impact Fee Total$ (net due after credit for existing uses) <br /> Fire Alarm: ❑Update Existing El New System tiNot Req'd Fee Schedule Used For Calculation(Year): <br /> Reason Fire Alarm Required: <br /> RCW 64.55 MF worksheet req'd for permit? ❑Yes In No <br /> Add'I RCW 64.55 docs required prior to final? ❑77``Yeslo Additional Notes: <br /> VALUATION CALCULATION: Total$ p J 00° <br /> Approved By: Date: ��;/�-` <br /> PUBLIC WORKS <br /> Intake OK by: Date: <br /> Intake Comments: .PW Review&Worksheet Needed if: <br /> 1� � I OSys Dev Eval: <br /> Additional Notes: Da3 /[dr1 Grrfr-rL ^a ❑Water ❑Sewer OStorm <br /> /A DJ G✓// mod �/�Wl1 r1' 7� j OTraffic Mitigation Eval <br /> Approved By: �ir�lSl1 Date: 5✓✓ r 'OSite Work/Drainage(shown/triggered) <br /> I OAddress Letter <br /> FIRE DEPARTMENT j OBackflow Prevention for high hazard: <br /> Separate/Deferred Submittals Required: (dental,medical,pr animals,i mortuary, <br /> p q hospital,supportive housing) <br /> ❑Fire Sprinklers ❑Fire Alarm ❑Other: ' <br /> Additional Notes: ❑ This Permit is Approved by Public Works <br /> ❑ See PW Review Worksheet and associated attached items <br /> Fire Dept.Fees: ❑A Separate PW Permit is Required(Permit#: PW <br /> ❑ Review of As-Built Plans-NO FIRE FEE AND ❑ Is fully digital <br /> ❑ Minimal or No Fire Scope-NO FIRE FEE ❑ Is located in this folder <br /> ❑ Review/Inspection Scope-ADD FIRE FEE ❑ Is in a Separate Green Folder(join with this folder for permit issuance) <br /> Approved By: Date: ❑ 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 /> ELECTRICAL/PLUMBING Additional Notes: <br /> Additional Notes: <br /> Approved By: Date: Completed By:A/ agal.a.„.4, Date: (�/ 2 / 9 3 <br />