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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 />BidgIflddn/Rem Size <br />3— SF <br />Garage/Accessory Struct. Size <br />Number of Stories <br />Basement <br />[]No ❑Yes , Fin / Unfin <br />Type of Construction <br />j <br />Occupancy Group <br />15 <br />Occupancy Load <br />Cert. of Occpuancy Required? <br />o <br />Yes ❑Shell Only <br />Code Year <br />021 1:12018. 112015 <br />Fire Sprinklers: pdate Existing ❑New System ❑Not Req'd <br />Reason Sprinkler Required: <br />Fire Alarm: f3UpdateExisting ❑New System ❑NotReq'd <br />Reason Fire Alarm Required: <br />RCW 64.55 MF worksheet req'd for permit? ❑Yes ® No <br />Add'I RCW 64.55 docs required prior to final? ❑Yes No <br />VALUATION CALCULATION: Total $ ?g2�, <br />Additional Notes: <br />Approved By: Date: <br />52 <br />FIRE DEPARTMENT <br />Separate / Deferred Submittals Required: <br />El Fire Sprinklers ❑Fire Alarm ❑Other: <br />Additional Notes: <br />Fire Dept. Fees: <br />❑ Review of As -Built Plans - NO FIRE FEE <br />❑ Minimal or No Fire Scope - NO FIRE FEE <br />Review / Inspection Scope - ADD FIRE FEE <br />Approved By: T Wyn Date: 5- <br />ELECTRIC- 'PLUMBING <br />Additional Notes: <br />Approved By: Date: <br />PLANNING <br />Intake OK by: Assign To: Date: 5i <br />Intake Comments: <br />Zone <br />ffiv <br />Overlay/Agreement <br />Nonresidential Uset— <br />Residential Use <br />Proposed No. of Dwelling Units: <br />Total No. of Dwelling Units: <br />Planning/Landscape Inspection Required before Final? ❑Yes RNo <br />"In Lieu" Fee: Type: Amount $ <br />School Impact Fee: Total $ 0 - <br />Calculated: Credit: <br />❑Everett School Dist ❑Mukilteo School Dist <br />Park Impact Fees for permits applied for after 1/112022: <br />Park Impact Fee Total (net due after credit for existing uses) <br />Fee Schedule Used For Calculation (Year): <br />F60A e— +0 E000. J (32v %rcv�ly UAk w— Coe sars <br />Additional Notes: <br />Approved By: a Date: 5 ., 2 <br />PUBLIC WORKS <br />Intake OK by: Date: <br />Intake Comments: [PWRevrew & Worksheet Needed if <br />❑Sys Dev Eval : <br />❑Water []Sewer ❑Storm <br />OTraffic Mitigation Eval <br />iOSite Work/Drainage (shown/triggered) <br />[]Address Letter <br />❑Backflow Prevention for high hazard: <br />(dental, medical, animals, mortuary, <br />hospital, supportive housing) <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 ) <br />AND ❑ Is fully digital <br />❑ Is located in this folder <br />❑ Is in a Separate Green Folder Qoin with this folderfor permit issuance) <br />rr��1 El Will be issued separately (Separate Green Folder, PW Issued ahead of Bldg) <br />R� Public Works has no scope on this permit --- PW Not Required <br />Additional Notes: <br />Completed B;_ Date: d ¢ 4.? ICAX <br />