Fillable 106 Public Works Permit Application (City of Everett)

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106 Public Works Permit Application (City of Everett)

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  • 27 check-boxes
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File type: PDF

U.S.A. forms for City of Everett

BROWSE CITY OF EVERETT (WA) FORMS

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DRAINAGE MITIGATION QUESTIONS:
FT IN HEIGHT STORMWATER DISCHARGES TO:
FT WIDE
o Combined Sewer
SF
o Separated Storm Sewer
LF
o Direct Discharge to Snohomish River or Puget Sound
FT TOTAL HEIGHT TRIGGERED REQUIREMENTS:
CY
o MR2 Only o MR1-5 o MR1-9
LF
QUANTITY OF PROPOSED HARD SURFACES:
LF Proposed Roof Area:__________________SF
LF Proposed Hardscape:_________________SF
Total New + Replaced:_________________SF
*Required for Work in Public Right-of-Way
CONTRACTOR EMAIL:
CONTRACTOR LICENSE #(REQUIRED):
EVERETT BUSINESS LICENSE #(REQUIRED):
CONTACT PHONE:
CONTACT EMAIL:
PW
Owner/Authorized Agent Signature Date
PERMIT #
ADDITIONAL DESCRIPTION (AS NEEDED):
OWNER / APP. MAILING ADDRESS:
CONTRACTOR NAME:
CONTRACTOR ADDRESS:
STREET
STREET
o CUT/BORE IN PAVEMENT (PARALLEL)
o CUT/BORE IN PAVEMENT (NON-PARALLEL)
o POLE WORK / AERIAL / OVERLASH
OWNER / APPLICANT NAME:
(Revised 1/72019)
3200 CEDAR STREET, EVERETT, WA 98201
IF APPLICABLE: o LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.)_______________________________________________________
o FENCE IN ROW
o DRIVEWAY APRON / CURB CUT
o ASPHALT / CONCRETE PAVING
o RETAINING WALL / ROCKERY IN RIGHT-OF-WAY
o RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT
ACKNOWLEDGEMENT: I 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. I 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 18.27 RCW and 296.200A WAC.
DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK
IF APPLICABLE: o FRANCHISE/UTILITY COMPANY, ANNUAL BLANKET PERMIT #______________________________________________
SITE WORK FOR PROJECT TYPE:
oSFR-DETACHED oTOWNHOUSE oDUPLEX oADU oMULTI-FAMILY oCOMMERCIAL oINDUSTRIAL
UTILITY COMPANY'S NAME & JOB #: ___________________________JOB # _________________________________
PUBLIC WORKS PERMIT APPLICATION
PROJECT ADDRESS:
(P) 425-257-8810 | FAX 425-257-8857 | (E) everetteps@everettwa.gov | https://everettwa.gov/permits
PROJECT SITE INFORMATION
CITY OF EVERETT PERMIT SERVICES
CITY STATE ZIP
CITY STATE ZIP
CONTRACTOR PHONE:
CONTACT NAME:
o OWNER / APPLICANT o CONTRACTOR o OTHER (Architect, Engineer, Etc.) _________________________
City of Everett Official Use Only
CONTACT INFORMATION
o CLEARING / GRADING / FILL / EXCAVATE
PRIMARY CONTACT:
OWNER / APP. PHONE:
OWNER / APP. EMAIL:
CITY STATE ZIP
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106 Public Works Permit Application (City of Everett)

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Completed 13 February 2021

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