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Date,!�� � <br /> Puelic WaiFs Permp• <br /> Application For aiao.oeo��• ������ a P�O <br /> PUBLIC WORKS PERMIT PublitWarknFee <br /> Tolal Fe� S. <br /> Lesa AOP�Fee Peld S <br /> Belnnca Due s <br /> Print or Type Oniy <br /> Ao�1„�Prf�,,o.,.f-� SMai1�9Add2�9 ,� 1 �,E�. .D.� ��//Pv� u�A �H 399. 3 <br /> City 21p Phone <br /> �/A I„PI�i/.f4i �M I Mfi )U ��/N � ���5-ay/ J'y���i P�/ �� <br /> Applicant M ling Address City Zip Phone <br /> Describe Proposed Work �������:1t�n(�,lQ1�[�/f(/1t6G--- �nD����l��l��--T- <br /> � <br /> _ /� W <br /> Prolec�Address(If known) � .�c.�C4�1�L�� �(}�Q�--�l � <br /> J � <br /> Attach four(4)copies of plans for proposed work• Draw to scale and note the following as applicable: � <br /> • Property lines • Centerline of streel �/A �. <br /> � Outline and dimensions ot all existing and • Indicate North ��/ <br /> pruposed structures on the lol • Show any proposed grading changes <br /> • Exis�ing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls lor inspection shall be made 24 hrs. in advance- phone 259•881 5. � � <br /> 2. All work shall be performed in accordance with this permit and current City of Everett Desi�n and Construction <br /> Standa,ds and Specificatlons. <br /> 3. Call Location Underground Service 48 hrs. belore you dig.TOLL FREE NUMBER 1•800-424-5555. � <br /> ��,�;�� �-�c,�',�=s �F,c�,.r„= �.,��i O <br /> �E���,%�E� � <br /> c�;�� _�,, �3fo � <br /> ,',� <br /> O <br /> a <br /> ACKNOWLEDGEMEN�(OF CONDITIONS <br /> The undersigned owner/applicant hereby ac�rees�o hold and save harm• <br /> less the City ol Everett from any and all claims for damages, costs, <br /> expenses, or causes of action ihat may arise becauso of installation <br /> and maintenance of the improvement or other right�ol-way use hereto <br /> applied tor and further agrees to remove same upon notice from Ihe <br /> Approved for Consiruction Date City and to replace pub�ic properry damaged ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITIi1N <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAG[OF WOi7K ON THIS <br /> Phone: 259-8815 PROJECT OVER 90 DAYS DURATION. <br />