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l r PL19LIC WORKS PERMIT AnPLICATION CITY OF EVERETT PERMIT SERA,.1JES EVERETTSUBMITTAL.INSTRUCTIONS:Emall application&submittal documents to PermitServices@everettwa.gov or drop off at 3200 Cedar Street 2nd Floor Drop Box waSHtNG70N CONTACT INFORMATION:(P)425-257-8810 1(E)PermltServices@everettwa.gov I(W)everettwa.gov/permits ry ... y •`PRO`JECgT.$ITE INFORMATION , . x p" � t >. v PROJECT ADDRESS: —9// T Eve t/`e SITE WORK FOR PROJECT TYPE: SFR-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# E UTILITY COMPANY'S NAME&JOB M JOB M I , > r DESCRIR'TION T'011Vf 'jf 1N y f �- FILL IN ALL QUANTITIES OF WORK BlrLOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: ❑ FENCE IN ROW � FT IN HEIGHT STORMWATER DISCHARGES TO: ❑ DRIVEWAY APRON I CURB CUT FT WIDE ❑Combined Sewer i ❑ASPHALT/CONCRETE PAVING SF ❑Separated Storm Sewer i ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑ Direct Discharge to Snohomish River or Puget Sound ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: ❑CLEARING/GRADING 1 FILL I EXCAVATE CY ❑ MR2 Only ❑ MR1-5 ❑MR1-9 ❑CUTIBORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Root Area: SF I ❑POLE WORK/AERIAL I OVERLASH � LF Proposed Hardscape: SF ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF � P vv C ,trc/ ocJr1t r i i OWNER I APPLICANT NAME: {�Y�QV) a rAd I II OWNER/APP. MAILING ADDRESS: STREET f Q / a , y S 6 Ve r 4 CITY STATE 99,70-01 ZIP OWNER I APP. PHONE: OWNER I APP, EMAIL: `Required for Work in Public Right-of-Way CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE_ 21P CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED); EVERETT BUSINESS LICENSE#(REQUIRED): PRIMARY CONTACT: OWNER /APPLICANT ❑CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: 06 0 i� CONTACT EMAIL: P yl y' , a I d C, ACKNOWLEDGEMENT.,I have reviewed this application and confirm the information contained herein is true andfIrrect, Work done p suant to this ®milt must comply with current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviations mus 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 1) 0�3 It P V 2302 oll� OwnerlAuthorized Agent Signature Date (Revised 412112022)