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,�,. A, <br /> ���tl _ <br /> �`„� � D8t9J�L I� �. . a„oecwo��.v.,cmm���1��/-�o_ <br /> ��'�j� Applicetion For eiac o.o� •��p(�.�f� <br /> ��� PUBLIC WORKS PERMIT P��towFae�ea s <br /> � � LeuAopi feaF�iC 3_ <br /> BebncsOm S <br /> Print or Type Only <br /> �A �'s Yi I ��`7 AI►�r�-y-� � �rP�(-'�l�Q� �'a�l� �R <br /> �M Owner Mellinp Adtlress City Zip Phone <br /> �u —�APpllcent I Mailinp Atldress CitY ZiP Phone <br /> M� Deecrlba Proposed Work �rr����/V[ �� T'`�[Jt'� <br /> O(A <br /> __.__ J <br /> E W <br /> Pro�eet Addrese III known) � <br /> Allaeh lour(4)coD�ee ol plane lor proposad work-Drew to scelo end nola Ihe lollowing as appllcable: � <br /> • Properly Llnee •Centerline ol alreel � , <br /> �Outline and dimenaiona of ell eaintinp and • InOicate Norih <br /> �1 pro0asetl tlructurea an Ihe lot • Show any proposed grading chenpes <br /> • EMlatlnp and propoaed utllillea • Show measu�emenls � <br /> I�' O NO WRITE BELOW THIS LINE O <br /> '�' PERMI?CONDITIONS <br /> 1.All ull�lor Inepection ehall be made 24 hra.In advence•phone 259�8810. � <br /> 2.All work ehell be peAormed In eccordenee wllh Ihia permit end current Clly of Everett Desipn and Conatructlon <br /> 1�/ 3tandarde and Speciflcations. <br /> ' 1 3.Call Locatlon Underqround Servica 48 hrs.before you dip.TOLL FREE NUMBER 1•800�424�5$$b. � <br /> � <br /> 1_I N U i-/w P��M � � �z� � <br /> j � �i>� M�sc.. � <br /> 1 ' �S/�� � <br /> -' a <br /> _� <br /> _�- <br /> ACKNOWLEDOEMEN7 OF CONOITIONS <br /> The undersigned owneVapplicant nereby egrees lo hold and save ha�m� <br /> less the City ol Everelt Irom eny and all claims lor damages. cosls. <br /> expenses. o� ceuses of aclion Ihal may arise becausa ol inslatlatio� <br /> and maintenance ol the improvament nr other righboi-way use herelo <br /> epplieG for end lurlher agrees to removn same upon nolice Irom the <br /> Approved tor Construction Dat� Cily and Io repleco public property demaBed thereby. <br /> FINAL INSPEC710N Date <br /> Approvad ee Conatrucled Signalure ol Applicanl Date <br /> everet[ PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MIIST BE STARTED WITHIN <br /> � 3200CeCarSireet 180 DAYS OF DATE PERMIi IS ISSUED AND THEREAFTER IS TO <br /> Everet6 WAB8201 BE DILIGENiLV PURSUED TO COMPLETION.THIS PERMIT MAV BE <br /> Phone:259•8810 CANCELLED BV THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90�AYS DURATION. <br />