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r PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES ely ,A +C EVERETTSUBMITTAL INSTRUCTIONS:Emall appllcatlon&submiilai documenis to PermllServicos@everothva.gov or drop off at 3200 Coder Sireel 2nd Floor Drop Box WASHINGTON CONTACT INFORMATION:(P)426-257-88101(E)ParmltServices@everettwa.gov I(W)everettwa.gov/permits AT zr b Nx t_zt L t xt#'.'.: t 1 p i1}rEril L✓� ��z s iNF9RMION,: PROJECT ADDRESS: ,/� �, G} � { - (9 fef 5 S" SITE WORK-FOR PROJECT TYPE: (SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX OADU IJMULTI-FAMILY EICOMMERCIAL ❑INDUSTRIAL IF APPLICABLE: EI LAND USE PROJECT#t(SEPA,PRE-APP,SS, ETC.) IF APPLICABLE: ❑FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT## UTILITY COMPANY'S NAME&JOB tl: JOB M itr -.•r:. 5j ,r.1.�.i- f J R'{f �_ - 4 . 5 ,, t �•1 ;)I f.VV?:7- r t. MWWFI*46 t R.�E;IF�'.VUO�RiC 14:R I\i H51�Ndo1! !,?ff Ol�W �?�j i�l,:a�. FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS,, CJ FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: GIDRIVEWAY APRON I CURB CUT FT WIDE ®Combined Sewer M'ASPHALT/CONCRETE PAVING _ "� (o ` SF ❑Separated Storm Sovrer O RETAINING WALL I 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: Cl CLEARING I GRADING 1 FILL I EXCAVATE CY d MR2 Only 13MR1-5 D MR1-D El CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: El CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF El POLE WORK I AERIAL/OVERLASH LF Proposed Hardscape: r SF ADDITIONA DESCRIPTION(AS NEEDED); Total New+Replaced: SF Add GTA r q- 4, ext r ` / I Pik -ro r,..;,..:. _,:y} {' ri r3} a}u ,; ., i P l- 4 r .a } yktii}' f� ! ti.f.�T ,:.<�� ti v �� 3�ar' a 1 to e,rzy I 11111 SON; FACT I►f>f?,01VI�'t'�0 i rig;,. _; 3 ..r" .� OWNER/APPLICANT NAME: OWNER/APP. MAILING ADDRESS: STREET Q CITY y' STATE OWNER 11 1 APP.PHONE: OWNER I APP.EMAIL: -I'fif r 1d1 1_r (,, , ti¢�.• 'Required for Work In Public Right-of-Way CONTRACTOR NAME: CONTRACTOR ADDRESS: sTr=�eT oily STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE t#(REQUIRED): EVERETT BUSINESS LICENSE fl(REQUIRED):• PRIMARY CONTACT: OWNER /APPLICANT 0 CONTRACTOR © OTHER(Architect,Engineer, Etc.) CONTACT NA B PHONE:fVYJ MORA1,4, CONTACT PHONE: CONTACT EMAIL: �, n f, ACKNOWLEDGEMENT,f have rovlowod this application and confirm Ilia Information contained heroin/s fare and correct, Vkk 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 Iha Building Official before being authorized under apy circumstanco,1 am ilia owner,or I on;authorized by tho owner of this property to perform ilia work for which application is made,and I comply with the State Contractors Low 18.27 RCW and 206.200A WAC. PERT# City of Everelt Official Use Only PVV Owner/Aulhorixed Agent Slgnatu ale I (Revised412112022)