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,� LIC WORKS PERMIT APPLICATION <br /> `�� CITY OF EVERETT PERMIT SERVICES <br /> -r 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT.SITE INPORMAT1ON. .:;'. <br /> PROJECT ADDRESS: '` O -X r- ,, GivextAk. 1\), F\ fi t \ <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED OTOWNHOUSE 0 DUPLEX OADU ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE APP,SS,ETC.) <br /> IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> '..' ,. , DeltitiPTiottQtitert 1[C►RKililiehiViAY.i111ail :'. .."w <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> OLFENCE IN ROW FT IN HEIGHT STORMNATER DISCHARGES TO: <br /> 0 DRIVEWAY APRON/CURB CUT FT WIDE 0 Combined Sewer <br /> O ASPHALT/CONCRETE PAVING SF 1 Separated Storm Sewer <br /> O RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF 0 Direct Discharge to Snohomish River or Puget Sound <br /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY 0 MR2 Only 0 MRI-5 0 MRI-9 <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF <br /> 0 POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): Total New+Replaced: SF <br /> OWNER I APPLICANT NAME: ,a <br /> OWNER/APP. MAILING ADDRESS: sTrteer a I' <br /> CITY STATE %A ZIP <br /> OWNER/APP.PHONE: I t ) OWNER/APP.EMAIL: /(. $ <br /> *Required for Work in Public Right-of-Wk <br /> CONTRACTOR NAME. A <br /> C\f‘. 1 r.„<Aki Di ,,,,.. ,.„„,—, st...... st <br /> CONTRACTOR ADDRESS: STREET g, <br /> cITY ["c.) ,.. STAT .A.." .1.: <br /> CONTRACTOR PHONE: 41,4. .((11Q atIP CONTRACTOR EMAIL: ---f0,(0°)(01k.. A - <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUI RED): <br /> — <br /> PRIMARY CONTACT: 0 OWNER I APPLICANT C CONTRACTOR 0 OTHER(Architect,Engineer,Etc.) <br /> CONTACT NAM)NI <br /> t ..� 1 <br /> CONTACT PHONE: 1"12,,,c'- c-7(1- < •p q , ff ! - 13 !I % CONTACT EMAIL: fi :.at. .f , irn eti l' 001T.ACKNOWLEDGEMEN1 have reviewed this application and confirm the information contained herein is true and correct.Wdone 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.I am the owner,or 1 am authorized by the owner of this property to <br /> perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> / <br /> 3 iZI-1 Lc( PERMIT# <br /> City of Everett Official Use Only <br /> / �b <br /> PWS 3O ( <br /> Owner/Authorized Agent Signature Date (Revised 1/72019) <br />