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/ } �o ^� PvpbcWorkePermll� �f—� <br /> Date � c' ��- � <br /> Biap Oeo��� <br /> Application For <br /> PUBLI� WORKS PERMIT PuoTo�FeeFee s <br /> ' Leu�oo�Fee Pue f <br /> B�IenceDue S 'r�� <br /> Print or Type Only <br /> `�����,-- l�� �6/v l,�Q��''�or��`i��1�i�1>/ <br /> Owner <br /> Mailing Address ..ity ZiP Phone <br /> � <br /> �o�_ c�rs 75'�i`�ir�✓� ��� r � 9�3�d� �-2-�i � <br /> Z�P Phone n <br /> ApP11Ce�� Mailing Address �'�1' p� <br /> �3"/ !�P GJ J'i� ri � �c1" (1 `3 �'' c�X� � �>'. 1�,2 <br /> Describe Propased Work <br /> ✓� M M <br /> W y � <br /> � �� <br /> z � . � � Y F- � QQQ <br /> prole��Address lif known) � <br /> � y <br /> Attach four(4)copies o1 plans lor proposed work• Draw to scale antl note Ihe lollowing as applicable: � � <br /> • Property Lines • Centerline of street � <br /> • Indicate North <br /> • Outline end Cimensions o1 ell exisling and � Show any Proposed grading changes <br /> proposed structures on the lot � � ~ <br /> • Ezisting and proposed utilities • Show measurements Zy <br /> DO NOT WRITE BELOW TFiIS LINE O N <br /> PERMIT CONDITIONS � O � <br /> 1. All calls for inspection shell be made 24 hrs. in advance-phone 259-88�5. � <br /> 2. All work shell be pertormed in accordance with ihis pe�mit and current City ol Everett Design and Consiruclion � <br /> StanderAa and Specificationa � �+ <br /> 3. Call Locatioi� Underground Service 48 hrs.before you dig.TOLL FREE NUMBEN 1•800'424�b555. y <br /> 5! �!/EGJ IX'/vEa✓Q� Tn dE TiEo iiv H/�ri/ O � � <br /> A��E'`' E,vr.c>e.vc E'. � • � <br /> S INSTdGG Cer�� ,�S"v - �"yrE A � � <br /> ciry sre.r/oa2p �f�o2� !�//r�lin <br /> O/L SEvE,cera�c:•%asTi-dv . O � <br /> a N <br /> � <br /> H <br /> � <br /> ACKVOWLEDGEMENT OF CONDITIONS <br /> The undersianed owner/applicant hereby egrees to hold and save harm� <br /> less Ihe City ol Everett Irom any and all claims for damages, cosis, <br /> fc.C.C'f.'�/L:di•.rk=='�'��f ��- expenses, or causes of action ihat may arise because ol installetion <br /> and maintenance ol the improvement or other righ4of-way use hereto <br /> ���C��� �-J �'t appfied for and luriher agrees lo remove same upon nolice from the <br /> Approved o�Construclion � ���e City anJ(q re�lace public propefty damaged lhereby. <br /> � , � � � 3- ��-e� �: ���� � �- /-� 'L�'-Sr'� <br /> AL INSPECTION Date Date <br /> 5 gnature ol A icant <br /> Approved as Constructed <br /> WORK AUTHORIZED BV THIS PERMIT MUST BE STARTED W�THI <br /> Oeve�ett PUBLIC WORKS DEPARTMENT t80 DAY:, OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3200 Cedai Street BE DILIGENTLV PURSUED TO COMPLETION. THIS PERM�T MAY BE <br /> Everett.WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 253�8815 PROJEC7 OVER 90 DAYS DURATION. <br />