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i <br />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 />Bldg/TI/Addn/Rem Size <br />Garage/Accessory Struct. Size <br />Number of Stories <br />Basement <br />[]No ❑Yes , Fin / Unfin <br />Type of Construction <br />t9c <br />Occupancy Group <br />1 r C <br />Occupancy Load <br />(2-C <br />Cert. of Occpuancy Required? <br />No ❑Yes ❑Shell Only <br />Code Year <br />102021 W2018 112015 <br />Fire Sprinklers: ❑Update Existing ❑New System lot Req'd <br />Reason Sprinklers Required: <br />Fire Alarm: ❑Update Existing ❑New System Not Req'd <br />Reason Fire Alarm Required: <br />RCW 64.55 MF worksheet req'd for permit? ❑Yes 12 No <br />Add'I RCW 64.55 docs required prior to final? ❑Yes No <br />VALUATION CALCULATION: Total $_ZS 000 <br />Additional Notes: <br />Approved By_. <br />Date: Gi 2Ll <br />- <br />FIRE DEPARTMENT ' <br />Separate / Deferred Submittals Required: <br />❑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: Date: <br />ELECTRICALIP-LUMBING <br />Additional Notes: <br />ApprovedBy: Date: <br />PLANNING <br />Intake OK by: Assign To: VU% Date: 1S tJ OV 24" <br />Intake Comments: <br />Zone <br />1ZI <br />Overlay/Agreement <br />lxf tvw►a { <br />Nonresidential Use <br />Residential Use <br />Sir <br />Proposed No. of Dwelling Units: <br />Total No. of Dwelling Units: <br />Planning/Landscape Inspection Required before Final? ❑Yes Slo <br />"In Lieu" Fee: Type: Amount $ N Ili <br />School Impact Fee: Total $ PIA <br />Calculated: Credit: <br />❑Everett School Dist ❑Mukilteo School Dist <br />Park Impact Fees for permits applied for after 11112022: <br />Park Impact Fee Total $ ' 4 I (net due after credit for existing uses) <br />Fee Schedule Used For Calculation (Year): <br />Additional Notes: <br />Approved By: Date: <br />PUBLIC WORKS <br />Intake OK by: Date: <br />Intake Comments: ;PW Review & Worksheef Needed if. <br />1 ❑Sys Dev Eval : <br />❑Water ❑Sewer ❑Storm <br />[:]Traffic Mitigation Eva[ <br />(]Site Work/Drainage (shown/triggered) <br />❑Address Letter <br />6 <br />ID Backfiow Prevention for high hazard: <br />i(dental, medical, animals, mortuary, <br />hospital, supportive housing) <br />i <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 />❑ WIII be issued separately (Separate Green Folder, PW issued ahead of Bldg) <br />PPublic Works has no scope on this permit --- PW Not Required <br />dditional Notes: <br />Completed By: ' Date: 7 2d <br />WINES <br />