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04' PUBLIC WORKS <br /> REVIEW WORKSHEET <br /> (ATTACH 1 SITE PLAN FOR REVIEW) Date: 10/11/2016 <br /> Permit#: PW1610-021 <br /> PROJECT ADDRESS: 5701 LOMBARD AVE SE <br /> DESCRIPTION OF WORK: SITE WORK FOR SFR 2 STORY ADDITION AND REMODEL <br /> CONTACT INFORMATION: <br /> OWNER: APPLICANT: <br /> NAME: BROCKWAY JENNIFER NAME: [AppName] <br /> ADDRESS: 5701 LOMBARD AVE ADDRESS: [AppAdd] <br /> EVERETT,WA, 98203 [AppCi], [AppSt], [AppZip] <br /> PHONE: PHONE: [AppPhone] <br /> EMAIL: EMAIL: [AppEmail] <br /> CONTACT: 0 Owner 0 Applicant ❑Other <br /> NAME: [ContactName] <br /> PHONE: [ContactPhone] <br /> EMAIL: [ContactEmail] <br /> COMMENTS FROM PUBLIC WORKS REVIEWER: LAND USE PROJECT#: <br /> PW Permit Required?'YES 0 NO W.O.#: / <br /> Notes: 0 0. t (tittriv11trcz /stouAssociated Bldg./PW Permit#: (�,�b D q"d24 <br /> FIRE SPRINKLER REQUIRED?(by Fire Department/Code) <br /> 0 YES-Type (If yes, add to TRAKiT under Reviewer Comments on Bldg Permit and Stamp Drawings) <br /> VI NO <br /> Explanation: Fue woe - h yds A c&r &_ 7'1350 <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$ 0 YES-Amount$ <br /> 0 Meter Only, 0 Complete Service, Size ❑3/4"Detect Meter Only, 0 Fire Service Size <br /> Ig NO 12t NO <br /> Explanation: c,,-(,( , FbdSitnc In /STAVIZ)e., Explanation: <br /> ❑ RPBA Needed at premise?-(Plumbing permit for backflow device needed due to High-Hazard Site per Tim Markham's review) <br /> ❑Water Department Cost Estimate Needed-(/f yes, PW Reviewer to send cost estimate request to Water Department, attach copy) <br /> Existing Utility Permit#(if applicable): <br /> SEWER FEE? <br /> ❑YES-Amount$ 0 New Connection, 0 Alteration/Repair, 0 Cap-off/Reconnect <br /> IEC NO <br /> Explanation: e c-(.(,Iri E1 rt►la ,p 11 ,r te/ <br /> Existing Utility Permit#(if applicable): <br /> SYSTEM DEVELOPMENT FEE? <br /> b YES-Amount$ 0 See Attached Spreadsheet <br /> 'NO- o Chang- of Use/Other <br /> Explanation: - <br /> (Note:Public Works Reviewer to Add Traffic Mitigation to PW Permit(if applicable)) <br /> TRAFFIC MITIGATION FEE? <br /> ❑YES-Amount$ 0 See Attached Spreadsheet <br /> �(NO <br /> ADDRESS LETTER REQUIRED? (If yes (new assigned address), print out Address Letter from TRAKiT Print Menu and include) <br /> ❑YES-TYPE 0 See Attached Letter <br /> �NO <br /> PW Reviewer: I 1 ,• Date: <br /> REVISED 10/11/2016 <br />