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Date_2�L�;r � <br />Appiicalion For <br />PUBLIC WtyZ4CS �P��iMIT <br />Print or Type Only <br />'1 F l � <br />Applicant <br />Mailing Address <br />Oescribe Proposed Wark �7 ��� C e � ` I��f �� <br />Ro�act Address (if knownj <br />v„oi.: n:o,.e r�a, n�,� . //-.—'� <br />OioO Deci . /` ��' V,�'7�__— <br />P�oi�c woixe Fee S <br />Talel Fee <br />Leu ROG� fae PaiC S <br />B+�encv Dua S <br />Zip Phone <br />�/ c <br />`SJ J � / � J^ J <br />Atlach four (4) copies of plans lor proposed work - Draw to scale and no�e the follow�in9 as �pFhcatrle: <br />• Froperty Lines • Centerline of sireet <br />• Outline and dimensions ol all existing and • Intlicate Norih <br />proposed slrucWres on ihe bt • Show any proposed gratlin9 chan9es <br />• Existing and proposed utilities • Shew measurements <br />rnone <br />PERMIT CONDITlONS <br />1. All w��s tor inspection shall be made 24 hrs. �n advance - uhone 259•8815. <br />2. All work shall be performed in accordance wi�h this aermit and current City of Everett Design snd Cunctruction <br />Standards arid Specilications. <br />3. Call Locetion Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-600•424-5555. <br />� :: <br />� 1 '�"° ��5 f� f��,,,� r..� <br />1 << <br />�� � l�,r ,., . <br />gV� �� <br />1 �c ( �.� <br />� l�t' /�.ti , <br />�—I)-'S� <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approvnd as Constructetl <br />everett PUBLIC WORKS DEPARTMENT <br />� .1200 Cedar Streel <br />E'aerell WA 48201 <br />Phrne'259 �� 5 <br />ACKNOI'ILE�GE�dENT OF CONOITIJNS <br />The undersignetl ovm=Uapplicant here6y agrees to hold and save harm� <br />less the City oi Everett Irom any and ell claims for damages, costs, <br />expenses, or cnuses ol action that may arise because ul inslalla[ion <br />and main�enancti ol the imp�ovem=nt or other right-of�way �:se he�eto <br />applied for antl turther agrees to remove came upon notice irom the. <br />City and to replace pubiic proFerty damaged thereby. <br />Signature ct Applican� Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTFD WI1Hit: <br />IBO �AVS OF UATE FERMIT IS ISSUED AND iHEREAFTER IS ii. <br />BE DILIGC-NTLY PURSUED TO CO�dPLETION THIS PERGIIT t9A1" `i: <br />CANCLLLL� B'f � I� -'.J i'i UFON NY `:TI�F - GL O� :'.(' �'.�: (�'J l III_: <br />F'FOJE�T ONEH 6U ��1� DUR�TICf: <br />