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Date� � a�miic wa�ws aermn• <br /> Application For aioy.oao��•�� � �7� <br /> PUBLIC WORKS PERMIT Punf¢wo�w�Fae <br /> ioblFne a <br /> Lep AOG�Fae Pa1E f <br /> Pfint Of TypB Only e.�.��eo�. S <br /> l�a„ I �/--. L P leu 6a� Alve��nu ,��I✓d_ C✓eie ff �o'i-70�3 <br /> Owner Mailing Address Clly Zip Phone <br /> ��o�s CaK��, a311 I�6�f�,rcJ Di. Luke SyP✓'�s 9 &.zs� 3.7��5 / <br /> Applicant Melling Address City Zlp Phone <br /> �1 1 / 1 <br /> Deacrlbe Pr000sed Work _�.Old� 7iLw �i� Si na�P M��j(j�g __ <br /> Project Add�eea(if known) ���p��V�h✓1 ��✓D'l. � <br /> � <br /> Attech four(4)coDlee al plene lor propose�t work-Draw to scele end noto the lollowing es epplicable: � <br /> • Property Linee . • Centerline ol slreat � <br /> •Outline and dimenaione of ell e�xisling and • Indlcate North <br /> proposed etructurea on ihe lot • Show eny propoaed greding chengea <br /> • Exlatirp end proposed ulllitles • Show measurementa � <br /> 0 N WRITE BEL TMIS LINE O i <br /> PERMIT CONDITIONS <br /> 1. All calls lor Inepectlon ahall be r�ede 24 hra In advence•phone 259•881 5. � <br /> 2. All wonc ahell be pertormed In accordance witb thle permlt end current City of Everett Dealgn and Conshuctlon <br /> Stendarda end Speclllcatlona <br /> 3. Cell Laatl�n Undarground Servi�:e 48 hre.before you dig.TOLL FHEE NUMBEN 1•800�424•5656. � <br /> r`vt7c-✓C; G�.�n�P�t'S f�E�.'miT it/oT ��CUi.e'EO <br /> ,�/o�� 0 <br /> NI <br /> � � <br /> i <br /> a � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The underelgnud awner/applicant hereby agreea to hold and eave harm- <br /> leas Iha City ol Everett Irom eny end ell clalms for damepes, coat0. <br /> expenaea, or causea ol actlon ihel may eriee because of Installatian <br /> and maintenence ol the improvement or other rlght•ol•way uae he�eto <br /> applled lor end fuhher pgreea to remove same upon notice irom the <br /> Approved lor Conetiuctlon Date City and to replece public property demeped thereby, <br /> FINAL INSPECTION Dale <br /> Approved ea Consfructed Slgnature of Applicent Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZ[D BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Ceder Streat 180 DAYS OF DATE PEHMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIGENTLV PURSUED TO COMPLETION.TNIS PERMIT MAY BE <br /> Phone:259•Bd15 CANCELLED BY THE CITY UPON ANY STOPPAQE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />