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1 <br />PUBLIC WORKS PERMIT APPLICATION " <br />CITY OF EVERETT PERMIT SERVICES <br />E V E R E T T <br />SUBMITTAL INSTRUCTIONS; Emil appacaeon A submCbldmummis to PeanlSarvkoalyevarease.90y or drop off at 3200 Cedor Street Ind FIM DMP Boy <br />WASHINGTON CONTACT INFORMATION: (PI426-267.884011E1 Pamntl9arviraittevaregw9.gov I(W) everstlWe.goV/permlis <br />.'S�s"ss�.�.'.,:%�.y�.i??,. �►� � 9T � . Q � � .l�l: '''1 E " '1;�� <br />PROJECT ADDRESS: I. _ - 5-lay, �—Lv <br />N � 1a� ''.} 4. � .. <br />it <br />SITE WORK FOR PROJECT TYPE: FR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI.FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br />IFAPPLICABLE: ❑ LAND USE PROJECT# (SEPA, PRE-APP, SS, ETC,) <br />IFAPPLICABLE:1]FRANCHISE/UTILITY COMPANY, �ANNUAL {BLLANKETPERMIT# [( <br />UTILITY COMPANY'S NAM�Er8, Alj : "D 1.0 ip— w <br />FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLM <br />❑ FENCE IN ROW ___ j Q fim; - , F"'I" Hr ItI6 FT IN HEIGHT <br />APRON/CURB CUT D FTWIDE <br />❑ ASPHALT ICONCRETE PAVING _ 110 rxxi- SF <br />❑ RETAINING WALL/ ROCKERY IN RIGHT-OF•WAY 0 .: LF <br />❑RETAINING WALL ROCKERY OVER 4FT I N H EIGHT �" _FTTOTALHEIGHT <br />❑ CLEARING / GRADING / FILL /EXCAVATE _ f2) ICY <br />❑ CUTA30RE IN PAVEMENT (PARALLEL) 'D LF <br />❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) ri LF <br />❑POLE WORK / AERIAL /OVERLASH 7�D LF <br />ADDITIONAL DESCRIPTION (AS NEEDED: <br />DRAINAGE MITIGATION QUESTIONS: <br />STORMWATER DISCHARGES TO.'❑DRIVEWAY <br />OornbinedSewer <br />❑ Separated Storm Sewer <br />❑ Direct Discharge to Snohomish River or Puget Bound <br />TRIGGERED REQUIREMENTS: <br />❑mony ❑MRIS ❑MR1-o ' <br />QUANTITY OF PROPOSED HARD SURFACES: <br />Proposed Roof Area: I q 8 % SF <br />Proposed Hardsape: 1772 SF <br />Total New+Replaced: %7gq SF <br />INN y <br />OWNER I APPLICANT NAME: '., <br />... <br />OWNER/APR3. MAILING ADDRESS: STREET '1 6III <br />V , tI , <br />CITY <br />STATE Wk pP <br />,p I- <br />OWNER/APP. PHONE:IWNERIAPP.EMAIL: A <br />iC Ardwoad <br />'Required for Work In Public Rln"ts.,"-• <br />CONTRACTORNAMEI'' (4ql LI r_ _ r ,w6A F LLC <br />CONTRACTOR ADDRESS: J STREET' 62 � <br />Om' U <br />���" p <br />STATE.{/v zv, g D <br />CONTRACTOR PHONE: Wjv <br />CONTRACTOR EMAIL: M <br />G l,' O 0 4 .7J, 1 IGfLtlfVj <br />CONTRACTOR LICENSE#(REQUIRED): IGHF902.MM H IMR&T <br />BUSINESS LICENSEt;(REQUIR_.):. C72,? 7 <br />PRIMARY CONTACT: ❑OWNER /APPLICANT CONTRACTOR ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME <br />�l 1Ci�rti>r� <br />' 1 I <br />CONTAGT,PHONE; ' <br />CONTACT EMAIL; • <br />nunwurvr:euvrmrnr: rnave revretroa mix sppecanon a aontlim are lmornUlor, contained hereirIs true and correct. Work donepursuant tows permit must <br />comply With currant lederal, state, and Aiallaw. The gran rg of a permit only atdhodzesapproved work and no devlallons fhamhom. Deviellons must8rst be <br />allihotked In witting from fhe Bulking Oklclal before being authorized undernny eircumsfenoe. Ism the owner, orient authorized bytho owner of this property to <br />perform the work tot whop apptcaf/on Is made, and I comply with the State Contactors Caw 18.27 RCW and 298.280A WAC. <br />City ofEvetefI OfBcle/ Use Only <br />PW. "13�g 0Z_o <br />(R6VIMed4/1ir2022I <br />