1340 MADRONA AVE 2025-08-19 - Laserfiche WebLink

PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS:Email application&submittal documents to PermitServices@everettwa.gov or drop off at 3200 Cedar Street 2nd Floor Drop Box WASHINGTON CONTACT INFORMATION:(P)425-257-8810 I(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits // `j (( PROJECT.SITE:INFORMATION t PROJECT ADDRESS: (104 (3�l� SITE WORK FOR PROJECT TYPE: *FR-DETACHED ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) IF APPLICABLE: ❑FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# UTILITY COMPANY'S NAME&JOB M JOB M :DESCRIPTION NO SITEWORK/ RIGHT�OFr1NXY'IMIORK ' ` t FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: ❑FENCE IN ROW FT IN HEIGHT STORMWA TER DISCHARGES TO: DRIVEWAY APRON/CURB CUT I'q FT WIDE ❑Combined Sewer ❑ASPHALT/CONCRETE PAVING SF ❑Separated Storm Sewer ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑Direct Discharge to Snohomish River or Puget Sound ❑RETAINING WALL I ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: ❑CLEARING I GRADING I FILL I EXCAVATE CY ❑MR2 Only ❑ MR1-5 ❑MR1-9 ❑CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF ❑POLE WORK I AERIAL I OVERLASH LF Proposed Hardscape: SF ADDITIONAL DESCRIPTION(AS NEEDED): `- Total New+Replaced: SF COINI�� �AVI�NORI�ATIO OWNER/APPLICANT NAME; OWNER/APP. MAILING ADDRESS: STREET D \ CITY �• STATE ZN OWNER/APP.PHONE: -61 40.•7_3 OWNER I APP.EMAIL: G(.Y"C,1n bti--1' &,A r & CC.t VkC_dS't—. V1e:t 'Required for Work in Public Right-of-Way CONTRACTOR NAME: i U b'Le_e_V— CONTRACTOR ADDRESS: STREET CITY \ ISTATE- � CONTRACTOR PHONE: CONTRACTOR EMAIL: n CONTRACTOR LICENSE#(REQUIRED): I�U V1�iWIG rj7�j bC YL EVERETT BUSINESS LICENSE#(REQUI ED):. U✓ PRIMARY CONTACT: XQWNER /APPLICANT ❑CONTRACTOR ❑OTHER 4Ar ' t Engineer, Etc.) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: r—i I—Vt 1�' Gv1MC drrj fL� ACKNOWLEDGEMENT.•l have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must 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 authorized in writing from the Building Official before being authorized under any circumstance.l am the owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 16.27 RCW and 296.200A WAC. City of Everett Official Use Only t PERM T 11- 1 - z Pw - 02D Owner/Authorized Age�nt Signature Date (Revised 412112022)