4201 RUCKER AVE COMMUNITY HEALTH CENTER 2019-04-10

4err PUBLIC WORKS REVIEW WORKSHEET (ATTACH 1 SITE PLAN FOR REVIEW) Date: 5/19/2017 Permit#: B1705-065 PROJECT ADDRESS: 4204 RUCKER AVE DESCRIPTION OF WORK: TI FROM OFFICE TO MEDICAL CLINIC&OFFICE SP-COMM HEALTH CONTACT INFORMATION: OWNER: APPLICANT: NAME: COMMUNITY HEALTH CNTR OF SNOH NAME: [AppName] CO ADDRESS: ADDRESS: [AppAdd] 8609 EVERGREEN WAY [AppCi], [AppSt], [AppZip] EVERETT,WA, 98208 PHONE: [AppPhone] PHONE: 4257893700 EMAIL: [AppEmail] EMAIL: CONTACT: 0 Owner 0 Applicant ❑Other NAME: MONDA JANET PHONE: 4258232244 EMAIL: COMMENTS FROM PUBLIC WORKS REVIEWER: LAND USE PROJECT#: ee!v iLl' 11'131/3 PW Permit Required? ❑ YES ❑ NO W.O.#: Notes: Associated Bldg./PW Permit#: 'l Ot5 l2_ FI5E SPRINKLER REQUIRED?(by Fire Department/Code) YES—Type (If yes, add to TRAKiT under Reviewer Comments on Bldg Permit and Stamp Drawings) 0 N Explanation: (Note:Counter Staff to Create Utility Permit for any Water/Sewer/System Development Fees) WATER FEES? DOMESTIC SERVICE: FIRE SERVICE: ❑YES—Amount$ 0 YES—Amount$ OMeter Only, 0 Complete Service, Size ,❑ 3/4"Detect Meter Only, 0 Fire Service Size N0 Explanation:045€. €4c Wailer 5'OWIrt, Explanation: 'KRPB qNeeded at premise?-(P/ mbing perrnit for backflow device needed due to High-Hazard Site per Tim Markham's review) ❑Water Department Cost Estimate Needed-(/f yes, PW Reviewer to send cost estimate request to Water Department, attach copy) Existing Utility Permit#(if applicable): SEWER FEE? ❑YES—Amount$ 0 New Connection, 0 Alteration/Repair, 0 Cap-off/Reconnect 7ECNO pp Explanation: t� —(A i Ve S E tAJ't4' Existing Utility Permit#(if applicable): SYSTEM DEVELOPMENT FEE? 'ES—Amount$Z0)15.36,92, , 'See Attached Spreadsheet ❑ NO—No Change of Use/Other Explanation: (Note:Public Works Reviewer to Add Traffic Mitigation to PW Permit(if applicable)) TRAFFIC MITIGATION FEE? ..'KYES—Amount$ )(See Attached Spreadsheet ❑ NO ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) EYES—TYPE QinfYON A K.— IKSee Attached Letter ❑ NO 7-REVPW Reviewer: ettlyvic4.4j1Date: / --2g-20(q-- REVISED ISED 10/11/2016 ��. / 1 ;