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PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EV E R E T T SUBMITTAL INSTRUCTIONS:Email application&submittal documents to PermitServices@everettwa.gov or drop off at 3200 Cedar Street 2nd Floor Drop Box <br /> WAS H I NCTO N CONTACT INFORMATION:(P)425-257-8810 1(E)PermitServlces@everettwa.gov I(W)everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: )U LG _ <br /> SITE WORK FOR PROJECT TYPE: SFR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: ET LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> IF APPLICABLE: ❑FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB#: <br /> DESCRIPTION-OF'SITE WORK/ RIGHT-OF-WAY WORK. , <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> FENCE IN ROW �j/ FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE ❑Combined Sewer <br /> ❑ASPHALT/CONCRETE PAVING SF ❑Separated Storm Sewer <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑ Direct Discharge to Snohomish River or Puget Sound <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> ❑ CLEARING I GRADING/FILL/EXCAVATE CY ❑MR2 Only ❑MR1-5 ❑MR1-9 <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF <br /> ❑ POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total Ne`w+Replaced: SF <br /> rt " <br /> c <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: 1 - <br /> �ICS Yr l 1 - c CL V1 Gl 0 1 C <br /> OWNER/APP. MAILING ADDRESS: STREET pU I` Ytt <br /> CITY �Y'�l <br /> STATE Zip c � <br /> OWNER I APP. PHONE: '2_06 ­. , - -Q C, OWNER/APP. EMAIL: �.Q �f>> a. �P,5 CL e C ).t C[7 al <br /> 'Required for Work in Public Right-of-Way o r a,de S"-x he <br /> CONTRACTOR NAME: <br /> n 2b <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE- Zip <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER /APPLICANT ❑ CONTRACTOR ❑OTHER(Architect, Engineer,Etc.) <br /> CONTACT NAME:) �. ©6 JXC a-j CONTACT PHONE: <br /> O CONTACT EMAIL: <br /> ACKNOWLEDGEMENT.,I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must <br /> 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 <br /> authorized in writing from the Building Official before being authorized under any circumstance* <br /> l am the owner,or I am authorized by the owner of this properly to <br /> perform the work for which applicall is made,and/comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> rpz <br /> o -(-Io ' z3l© — <br /> Owner/Authorized Agent S lnat Date �� (Revised 412112022) <br /> 0�ZS - t0c[ C9 <br />