o:\planning\forms and brochures\engineering permit application 2017.doc p. 1
Rev 12/12/2016
11930 Cyrus Way, Mukilteo, WA 98275
Phone: (425) 263-8000
http://mukilteowa.gov
permittech@mukilteowa.gov
Engineering Permit Application
Application Type Mark all those that apply
Clearing & Grading (Land Surface Modification) Right-of-Way Stormwater
Per MMC 15.16.010 Per MMC 12.01.010 Per MMC13.12
General Permit Information
PROJECT NAME:
PROJECT ADDRESS:
1. CONTRACTOR Applicant
Name___________________________________________
Address_________________________________________
City/State/Zip_____________________________________
24 Hour Phone____________________________________
State License #____________________________________
Mukilteo License #_________________________________
E-mail___________________________________________
2. PROPERTY OWNER Applicant
Name___________________________________________
Address_________________________________________
City/State/Zip_____________________________________
Phone___________________________________________
E-mail __________________________________________
3. PRIMARY CONTACT Applicant
Name___________________________________________
Address_________________________________________
City/State/Zip_____________________________________
24 HR Phone_____________________________________
E-mail __________________________________________
4. PARCEL NUMBER(S)
________________________________________________
________________________________________________
5. PROJECT DESCRIPTION
________________________________________________
________________________________________________
________________________________________________
6. TOTAL PROJECT AREA (INCLUDE ROW, IF ANY)
(SF)
7. TOTAL SITE AREA (SF)
____________________________________________
8. TOTAL GRADING QUANTITIES (CY)
(Use Total from pg. 2 , #4)
____________________________________________
9. IS A RETAINING WALL PROPOSED? YES or NO
10. EXISTING SITE IMPERVIOUS SURFACE COVER (%)
(Report Item 2 from Page 4)
____________________________________________
11. TOTAL NEW PLUS REPLACED HARD SURFACES
(SF) (Report Item 6 from Page 5)
12. TOTAL PROPOSED LOT HARD SURFACE
COVERAGE (SF) - (Report Item 7 from page 5)
0
0
0
o:\planning\forms and brochures\engineering permit application 2017.doc p. 2
Rev 12/12/2016
Clearing & Grading (Land Surface Modifications)
1. Total Area of Land Surface Disturbance (SF): _______________________________________
2. Vegetation to be Removed:
Evergreen Trees: ___________(canopy area) Deciduous Trees: ___________(canopy area)
Shrubs / Lawn: _____________(area) Invasive(s): ________________(area)
Other: ____________________(area) Invasive types
3. Method of Land Disturbance: Hand Clearing Machine
4. Land Disturbance Outside the Building Footprint:
Exported: (CY) Imported to Site: (CY)
Re-Graded on Site: (CY) Other: (CY)
Total (Add all Land Disturbance, Report on Page 1, #8)
5. Provide Address for Materials Disposal Site____________________________________________________
6. Maximum Height of Fill: _____________________ Maximum Depth of Cut: __________________
7. Identify any stream, surface water, drainage course, wetlands, or critical areas on or within 200 feet of the property:
Retaining Walls:
If a retaining wall is proposed, please check which applies (Height is measured from bottom of footing)
No retaining wall proposed ≥ 4 feet ≤ 4 feet and not load bearing Any height and load bearing
Right-of-Way:
Type of work being performed in City right-of-way:
Stormwater Frontage Improvements Driveway
Natural Gas Sewer Water
Telephone Power Cable
Other: _________________________________________________________________
Is this project adjacent to a State Route? Yes No
If Yes, WSDOT approval shall be required, and a copy provided with this application, including the WSDOT approved
Traffic Control Plan.
0
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Rev 12/12/2016
WHAT ARE HARD SURFACES and IMPERVIOUS SURFACES?
Hard surfaces include permeable pavement, decks, vegetated roofs, and all impervious surfaces.
Impervious surfaces are non-vegetated surface areas that either prevent or impair water entry into the soil.
These surfaces cause water to run off the surface in greater quantities or at increased flow rates from natural
conditions. Common impervious surfaces include, but are not limited to, roof tops, walkways, patios, gravel,
asphalt, concrete and bricked surfaces. (See MMC 17.08 for complete definition.)
Stormwater
Step 1. Determine if a Stormwater Permit is Needed
Does the project propose to:
A. Add new or replace 2,000 square feet or more of hard surface area? YES NO
B. Disturb 7,000 square feet or greater of land? YES NO
C. Connect to the City’s stormwater system? YES NO
If the answer to ANY of the above is “YES,” then a Stormwater Permit is required. Complete entire Stormwater Permit
Application and provide required submittals.
If the answer to ALL of the above is “NO,” then a Stormwater Permit is NOT required. Complete Steps #2 through #6 and
include a Short SWPPP form with your application.
Step 2. Calculate Existing Impervious Surface Area
Enter the area for all existing impervious surfaces on the property. Only include those items that are impervious.
Hard surfaces, such as porous pavement, will be considered in Step 3. If there are none to add, enter “0”.
TABLE 1 EXISTING IMPERVIOUS SURFACES
Types of improvements to
consider (not a complete list)
Existing Impervious
Surfaces Area (sf)
Describe area(s) included in SF (e.g. house, driveway,
etc.)
Roof Structures (all buildings)
Sidewalks / Walkways
Covered Porch / Deck / Patio
Driveway (include gravel
areas)
Parking Lot (incl. gravel areas)
Other
TOTAL
Item 1
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Rev 12/12/2016
Step 3. Determine if the Project is New Development or Redevelopment
TABLE 2 PERCENT EXISTING IMPERVIOUS COVER CALCULATION
A. Enter the total from Item 1 above
B. Total Site Square Footage
Existing Site Impervious Cover %
(A ÷ B) x 100
Report Item 2 on Page 1, #10.
Use result for Step 7. If <35%, project is new development. If >35%, project is redevelopment
Step 4. Calculate Existing Hard Surface Area
Enter any existing hard surfaces not included in the impervious surface calculation in Step 2. If there are none
to add, enter “0”.
Use Item 3 in Step 6.
TABLE 3 – EXISTING HARD SURFACES
Types of improvements to
consider (not a complete list)
Existing Hard
Surfaces Area (sf)
Describe area(s) included in SF (e.g. house, driveway,
etc.)
Green Roof Structures
Porous Sidewalks / Walkways
Porous Porch / Deck / Patio
Porous Driveway / Parking
Other
TOTAL
Item 3
Item 2
0
0%
0
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Rev 12/12/2016
Step 5. Calculate Proposed New and Replaced Hard Surfaces
Include all types of hard (and impervious) surfaces in the table. No “credit” is taken for replaced hard surfaces.
For example, if 1,500 sf of gravel is replaced with a 1,500 sf garage, this is entered as 1,500 sf replaced hard
surface. There is no deduction for the replaced gravel.
Report Item 6 on Page 1, #11.
Use Item 4 in Step 6 (do not include Item 5).
Step 6. Calculate Total Proposed Hard Surfaces
TABLE 5 TOTAL PROPOSED HARD SURFACES
A. Report Item 1 Subtotal (from Step 2)
B. Report Item 3 Subtotal (from Step 4)
C. Report Item 4 Subtotal (from Step 5)
TOTAL PROPOSED LOT HARD SURFACE COVER
Add A, B, & C
Report Item 7 on Page 1, #12.
TABLE 4 PROPOSED NEW PL
US REPLACED HARD SURFACES
(Enter “0” for sections not applicable to your project)
Proposed new PLUS replaced
hard surfaces
Describe area(s) included in SF? (e.g. house,
driveway, etc.)
New SF Replaced
SF
Roof Structures (all buildings)
Green Roof (not included above)
Sidewalks / Walkways
Covered Porch / Deck / Patio
Uncovered Porch / Deck / Patio
Driveway (impervious)
Parking (impervious)
Pervious Paving surfaces (all
All Right-of-Way Improvements
Others
SUBTOTALS
TOTAL NEW PLUS REPLACED
HARD SURFACES
Add Items 4 & 5
Item 4 Item 5
Item 6
Item 7
0
0
0
0
0
0
0
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Rev 12/12/2016
Step 7. Determine the Stormwater Minimum Requirements
Is the result on page 1, #10; 35% or more?
YES NO If yes, use Figure 2.4.2. If no, use Figure 2.4.1.
Figure 2.4.1
Flow Chart for Determining Requirements for New
Development (from Ecology Manual)
Minimum Requirement
#2 applies (Attach a
Short SWPPP Form to
the application)
Does the project result in
5,000 square feet, or
greater, of new plus
replaced hard surface
area
Does the project
convert ¾ acres or
more of vegetation to
lawn or landscaped
areas, or convert 2.5
acres or more of native
vegetation to pasture?
All nine (9) Stormwater
Minimum Requirements
apply to the new and
replaced hard surfaces
and converted
vegetation areas.
Does the project result in 2,000
square feet, or greater of new plus
replaced hard surface area?
Stormwater Minimum
Requirements #1
through #5 apply to the
new and replaced hard
surfaces and the land
disturbed.
Does the project have
land disturbing
activities of 7,000
square feet or
greater?
Yes
No
Yes No
Yes
No
Yes
No
Figure 2.4.2
Flow Chart for Determining Requirements for
Redevelopment (from Ecology Manual)
Does the project result in 2,000 square feet, or
more, of new plus replaced hard surface area?
OR
Does the land disturbing activity total 7,000
square feet or greater?
Stormwater Minimum
Requirements #1
through #5 apply to the
new and replaced
hard surfaces and the
land disturbed.
Minimum Requirement
#2 applies. Attach Short
SWPPP form to
application.
Does the project add 5,000 square feet or more of new
hard surfaces?
OR
Covert ¾ acres or more of vegetation to lawn or
landscaped areas?
OR
Convert 2.5 acres or more of native vegetation to pasture?
All nine (9) Stormwater
Minimum Requirements
apply to the new hard
surfaces and the
converted vegetation
areas.
Is this a road related
project?
Does the project add
5,000 square feet or
more of new hard
surfaces?
Do new hard surfaces
add 50% or more to the
existing hard surfaces
within the project limits?
Is the total of new plus
replaced hard surfaces
5,000 square feet or
more, AND does the
value of the proposed
improvements
including interior
improvements exceed
50% of the assessed
value of the existing site
improvements?
All nine (9) Stormwater
Minimum Requirements
apply to the new and
replaced hard surfaces
and converted
vegetation areas.
No additional
requirements
Next Question
Yes
Next Question
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
O:\PLANNING\FORMS AND BROCHURES\ENGINEERING PERMIT APPLICATION 2017.DOC page 7
Other
Anticipated Start Date: ______________________ Anticipated Completion Date: ______________
A Department of Ecology Construction Stormwater Permit is required for projects that disturb ≥1 acre. Will your
project disturb ≥1 acre of land through clearing, excavating, or stockpiling of fill? Yes No
If yes, complete NOI at http://www.ecy.wa.gov/programs/wq/stormwater/construction/enoi.html
A Forest Practice Permit is required for all projects removing and selling timber from the property site. Will your
project remove and sell timber? Yes No
A BNSF Permit is required for all projects that will discharge stormwater onto BNSF property (ROW). Does your
project discharge to BNSF ROW? Yes No
A Hydraulic Permit from the Department of Fish and Wildlife and / or from the Army Corps of Engineers is required for
all fill, or work within, over, or under a stream or wetland. Will your project involve stream or wetland?
Yes No
The list above is meant to provide guidance; it is the project applicant’s responsibility to identify and obtain all required
permits. All State, Federal, and/ or other applicable Permits shall be obtained and a copy provided to the City of
Mukilteo prior to issuance of the City of Mukilteo Engineering Permit.
The permittee shall indemnify, defend and hold harmless the City, its officers, agents and employees, from and
against any and all claims, losses or liability, including attorneys fees, arising from injury or death to persons or
damage to property occasioned by the construction, installation, operation, location, maintenance, or any other cause
related to the improvement for which this permit is granted. With respect to this permit and as to claims against the
City, its officers, agents and employees, the permittee expressly waives its immunity under Title 51 of the Revised
Code of Washington, the Industrial Insurance Act, for injuries to any employees the permittee may have, and agrees
that the obligation to indemnify, defend and hold harmless provided for in this paragraph extend to any claim brought
by or on behalf of any employee of the permittee. This waiver has been mutually negotiated by the parties as part of
the permitting process and is given, as is the indemnification agreement contained within this paragraph, as
consideration for issuance of a right-of-way use permit by the City. This paragraph shall not apply to any damage or
injury resulting from the sole negligence of the City, its agents or employees. To the extent any of the damages or
injuries referenced by this paragraph were caused by or resulted from the concurrent negligence of the City, its
agents or employees, this obligation to indemnify, defend and hold harmless is valid and enforceable only to the
extent of the negligence of the permittee, its officers, agents or employees, if any.
The acceptance of the conditions upon which this permit is granted shall be evidenced by the beginning of the
installation of said FACILITIES as set forth herein.
SEE ATTACHED INSURANCE REQUIREMENTS AND ACKNOWLEDMENTS. ADDITONAL SIGNATURE REQUIRED
.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PERMIT APPLICATION IN ITS ENTIRETY AND KNOW
THE SAME TO BE TRUE AND CORRECT. I AGREE TO COMPLY WITH ALL CONDITIONS, CITY ORDINANCES
AND STATE / FEDERAL LAWS REGULATING ACTIVITIES COVERED BY THIS PERMIT APPLICATION. I ALSO
ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO MAINTAIN PUBLIC STREETS FREE OF DIRT AND
DEBRIS.
_____________________________________________________ _______________________________________________________
Property Owner Signature Date
_____________________________________________________ _______________________________________________________
Applicant Signature Date
(if different than property owner)
click to sign
signature
click to edit
click to sign
signature
click to edit
O:\PLANNING\FORMS AND BROCHURES\ENGINEERING PERMIT APPLICATION 2017.DOC page 8
ENGINEERING APPLICATION CHECKLIST
Provide the following information as part of your submittal as required in Mukilteo Municipal Code 17.13
and the City of Mukilteo Development Standards.
Submitted
Yes N/A Document
Engineering Permit Application – 1
Stormwater Pollution Prevention Plan (SWPPP) 3 originals
Stormwater Site Plan (Drainage Report) 2 originals
Geotechnical Report – 2 originals
Civil Plan Set 3 originals
Wetland and Streams Report 2 originals
Transportation Impact Study 1 original
Transportation Concurrency Evaluation and Determination of Transportation Impact
Fees Form (if over 10 pm peak trips)1 original
Temporary Traffic and Pedestrian Control Plan2 originals
Soil Management Plan2 originals
Tree Preservation Plan 2 originals
Maximum Extent Feasible (MEF) Documentation1 original
Draft Statutory Warranty Deed (Right-of-Way Dedication), including Title Report,
Map, and Real Estate Excise Tax Affidavit Form 1 of each original
Evidence of Vesting Rights 1 original
Application for Alternate Material, Design, or Method of Construction 1 original
Application for Exception from Stormwater Minimum Requirements 1 original
Draft Declaration of Covenant/Maintenance Plan for Stormwater 1 original
Draft Access Easement for Stormwater 1 original
Draft Joint-Use and Maintenance Agreement for Private Roads/Joint-use Driveways
1 original
WSDOT approval if adjacent to State Route1 original
Other agency permits (list)(1 original each)
Wildlife Habitat Report 2 originals
Archaeology Report 2 originals
O:\PLANNING\FORMS AND BROCHURES\ENGINEERING PERMIT APPLICATION 2017.DOC page 9
INSURANCE
A. Insurance Term
The Permittee shall procure and maintain for the duration of the Permit, insurance against claims for
injuries to persons or damage to property which may arise from or in connection with operations or
activities performed by or on the Permittee's behalf with the issuance of this Permit.
B. No Limitation
Permittee's maintenance of insurance as required by the Agreement shall not be construed to limit the
liability of the Permittee to the coverage provided by such insurance, or otherwise limit the City's recourse
to any remedy available at law or in equity.
C. Minimum Scope of Insurance
Applicant shall obtain insurance of the types and coverage described below:
1. Commercial General Liability insurance shall be at least as broad as ISO occurrence form
CG 00 01 and shall cover liability arising from operations, products-completed operations,
and stop-gap liability. There shall be no exclusion for liability arising from explosion,
collapse or underground property damage. The City shall be named as an additional
insured under the Permittee’s Commercial General Liability insurance policy using ISO
Additional Insured-State or Political Subdivisions-Permits CG 20 12 or a substitute
endorsement providing at least as broad coverage.
2. Automobile Liability
insurance covering all owned, non-owned, hired and leased vehicles.
Coverage shall be at least as broad as Insurance Services Office (ISO) form CA 00 01.
D. Minimum Amounts of Insurance
Permittee shall maintain the following insurance limits:
1. Commercial General Liability
insurance shall be written with limits no less than $1,000,000
each occurrence, $2,000,000 general aggregate and a $2,000,000 products-completed
operations aggregate limit.
2. Automobile Liability
insurance with a minimum combined single limit for bodily injury and
property damage of $1,000,000 per accident.
E. Other Insurance Provision
The Permittee's Commercial General Liability insurance policy or policies are to contain, or be endorsed to
contain that they shall be primary insurance as respect to the City. Any insurance, self-insurance, or self-
insured pool coverage maintained by the City shall be excess of the Applicant's insurance and shall not
contribute to it.
F. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of not less than A:VII.
O:\PLANNING\FORMS AND BROCHURES\ENGINEERING PERMIT APPLICATION 2017.DOC page 10
G. Verification of Coverage
Permittee shall furnish the City with original certificates and a copy of the amendatory endorsements,
including the additional insured endorsement, evidencing the insurance requirements of the Permittee
before issuance of the Permit.
H. Notice of Cancellation
The Permittee shall provide the City with written notice of any policy cancellation, within two (2) business
days of their receipt of such notice.
I. Failure to Maintain Insurance
Failure on the part of the Permittee to maintain the insurance as required shall constitute a material breach
of the Permit, upon which the City may, after giving five (5) business days' notice to the Permittee to
correct the breach, immediately terminate the Permit, or at its discretion, procure or renew such insurance
and pay any and all premiums in connection therewith, with any sums so expended to be repaid to the City
on demand.
J. City Full Availability of Consultant Limits
If the Permittee maintains higher insurance limits than the minimums shown above, the City shall be
insured for the full available limits of Commercial General and Excess or Umbrella liability maintained by
the Permittee, irrespective of whether such limits maintained by the Permittee are greater than those
required by this contract or whether any certificate of insurance furnished to the City evidences limits of
liability lower than those maintained by the Permittee.
The acceptance of the conditions upon which this permit is granted shall be evidenced by the beginning of
the installation of said FACILITIES as set forth herein.
I HEREBY ACKNOWLEDGE THAT I HAVE READ AND AGREE TO COMPLY WITH THE
REQUIREMENTS REGARDING INSURANCE.
_____________________________________________________ _______________________________________________________
Applicant Signature Date
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