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� � � <br /> a� � � <br /> a � <br /> ��a <br /> �-, o �t� .�, "_ , F �w. <br /> H�l Date��- �, � � ���' <br /> O .."C O e e o vi ,��-�� "� •__1 � <br /> �w N Apphcahen For <br /> I� �x� PUBLIC WORKS PERMIT -- - - - -- <br /> PUULc W on s f e.e <br /> iolal Fpe $--- <br /> p�. � Le55P[�W �^FPaia S --- <br /> 6alanceDue .� <br /> p t�C� Print or Type Onry -- — <br /> �H [E ����� � y/� —�f� <br /> � �..�y ���� l�l �'�1�!��� � � � C.' ,��'� Y�f � ��� k� ��� ��r/LJ� <br /> ty�p Owner Madmg Address City 7ip Phone <br /> O N <br /> i- <br /> �d w �>� �x i��� � ��r� �� 7��-�I� <br /> ��r 1- -�a�.t s � /��� � � � � �� I <br /> Z y y ApDhcan� Mailing Address Qty Lp Phone <br /> HOrn //� <br /> Descrbe Proposetl Work ��� ��-���'"'� ��� <br /> �5��t L`�� S� ; � �� � � _=�.�, <br /> W <br /> Prolect Atldress�if known) � _ ����-�' . . � <br /> Attach tour 14)copies of plans for proposPtl wJrk- Draw to scale antl note the following as applicable�. � <br /> • Property LineS • Cen�erline of Sireet ,A <br /> • Outline and dimensions of all existing antl • Indicate North V� <br /> proposetl structures on the lot • Show any proposed grading changes <br /> • Existing antl proposed utilities • Show measurements � <br /> '�' DO NOT WRRE BELOW THIS UNE O <br /> ' ' PERMIT CONDITIONS <br /> � 1.All calls for inspection shall be matle 24 hrs.in advance-phone 2$9-881�. � <br /> 2.All work shall be performed in accordance with this permit and cu�rent City of Everett Design antl Construction <br /> '�' Standartls antl Specificaiions. <br /> 3.Call�ocation Untlergrountl Service 48 hrs.before you dig.TOLI FREE NUMBER 1•800•424•5555. � <br /> 1 � O <br /> 1-1 <br /> I 1 �� �� � <br /> - <br /> ►_� ��-�t�a�- Q I <br /> �_� � Qt - � cA - eq a � <br /> �_I � <br /> _� , <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> � <br /> The undersignetl owner/applicant hereby a9rees to hold and save harm� <br /> �' — less ihe Ciry of Everett from any antl all claims (or damages. cosis. <br /> e*penses. or causes ot action ihat may anse because o� installatio� i <br /> and maintenance of the improvement or other righbof-way use hereto <br /> applietl for and further agrees to remove same upon notice Irom the <br /> Approved for nstruction Oate Clty.ntl to replace public proper�y damaged thereby. . <br /> FINAL INSPEGTION Date — <br /> Approvetl as GOnstructed Signature ol Apphcant Date <br /> WORK AUTHOFIZED 6V �HIS PERMIT MUST BE STARTED WITHIN ' <br /> everett PUBLICWORKSDEPARTMENT 180 DAVS OF �ATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sfreet BE D�LIGEMLV PURSUED TO COMP�ETION THIS PERMIT MAV BE <br /> EvereR WA98201 CANCELLFD BV TNE GTV UPON ANV STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJEC7 OVER 90 DAVS DURATION <br />