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� PUBLIC WORKS �► <br />REVIEW WORKSHEET <br />(ATTACH 1 SITE PLAN FOR REVIEW) Date: 3/16/2016 <br />Permit #: C1603-024 <br />PROJECT ADDRESS: <br />DESCRIPTION OF WORK <br />4417 RUCKER AVE <br />SFR REPAIRS AND ALTERATIONS <br />CONTACT INFORMATION: <br />OWNER: <br />NAME: KARGOPOLTSEV GEORGE & GALINA <br />ADDRESS: 4417 RUCKER AVE <br />EVERETT, WA, 98203 <br />PHONE: 4253445450 <br />EMAIL: JDWELCH@MSN.COM <br />CONTACT: ❑ Owner ❑ Applicant ❑Other <br />NAME: KARGOPOLTSEV GEORGE 8� GALINA <br />PHONE: 4253445450 <br />EMAIL: JDWELCH(a�MSN.COM <br />COMMENTS FROM PUBLIC WORKS REVIEWER: <br />PW Permit Reauired? ❑ YES �O <br />Notes: No Si {-�' U.9 �K— a,�,( ..�;,�tE/?�/-o�'- <br />N � � �► c.�i�-� . <br />APPLICANT: <br />NAME: <br />ADDRESS <br />PHONE <br />EMAIL: <br />, <br />� <br />�C�;4� 1 V� fi lsL � 1��., V <br />KARGOPOLTSEV GEORGE & GALINA <br />4417 RUCKER AVE <br />EVERETT, WA, 98203 <br />4253445450 <br />JDWELCH@MSN.COM <br />LAND USE PROJECT #: <br />W.O. #: <br />Associated Bldg.lPW Permit #: _ <br />FIRE SPRINKLER REQUIRED? (bv Fire Department/Code) <br />❑ YES —Type (If yes, add to TRAKiT under Reviewer Comments on Bldg Permit and Stamp Drawinqs) <br />�'N O <br />Explanation: <br />(Note: Counter Staff to Create Utility Permit for any Water/Sewer/System Development Fees) <br />WATER FEES? <br />DOMESTIC SERVICE: FIRE SERVICE: <br />❑ YES — Amount $ ❑ YES — Amount $ <br />❑ Meter Only, ❑ Complete Service, Size ❑'/4" Detect Meter Only, <br />�N O `�N O <br />Explanation: Explanation: <br />❑ Fire Service Size <br />❑ Water Department Cost Estimate Needed-(If yes, PW Reviewer to send cost estirnate request to Water Department, attach copy) <br />Existing Utility Permit # (if applicable): <br />SEWER FEE? <br />❑ YES — Amount $ <br />�O <br />Explanation: <br />Existing Utility Permit # (if applicable): <br />SYSTEM DEVELOPMENT FEE? <br />❑ YES — Amount $ <br />� NO — No Change of Use / Other_ <br />Explanation: <br />❑ New Connection, ❑ Alteration/Repair, ❑ Cap-off/Reconnect <br />❑ See Attached Spreadsheet <br />(Note: Public Works Reviewer to Add Traffic Mitigation to PW Permit (if applicable)) <br />TRAFFIC MITIGATION FEE? <br />❑ YES — Amount $ ❑ See Attached Spreadsheet <br />�N O <br />ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) <br />�❑�' ES — TYPE ❑ See Attached Letter <br />� N� n � ,. <br />.� <br />Public Works Reviewer Signature <br />3 — 2 �—Z%� <br />Date <br />