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PunLc Worhe Va�mi1• �^�+ <br /> Date 7- � �h� i <br /> Blaa oeo��• <br /> Applicallon For _ <br /> PU�LIC WORKS PERMIT P��I¢Work�Fu �o �� <br /> Tol�l Fee s <br /> Lef��pp� Fee PUE S� <br /> PN�nce Due s 7� <br /> Print or Typs Only <br /> ��� ,� � e�U� � � 3y�s ���.�� �-����fl . (�..�ddZs zsz -�, <br /> Owner ailing AAdress Ci�y Zip Phone <br /> Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work _ N« �� �� �ri�4 �+v��i <br /> W <br /> Fro�ect Address(il known) �� �� — � <br /> � <br /> Attach lour(4)copiea of plens lor proposed work• Draw to scale and nota Ihe followiny as applicable: � <br /> • Properry Llnes • Cenlerline ol sireet <br /> • Oulline and dimensiona of ell oxistinq and • Indicate North <br /> proposaA atructures on ihe lol • Show any proposed greding chengos <br /> • Exiating enC pro0osed utilities • Show ineasurements M <br /> W <br /> n0 NOT WRITE BELOW THIS LINE � <br /> PEFHIT CONDITIONS <br /> 1. All calls lor inapoction shell be mede '.'.4 h�s. in etivance- phone ZB9•BE�S. � <br /> 2. P.II work shall te pedormed in accordenCe wlth ihi5 permit anL current City ol Everett Design and COnatruction <br /> Standerds end Specilications � <br /> 3. Call Location Unde�ground Service 4B nra. befrre yuu dig.TOLL FREE NUMBEH 1•800•424•.ri555. <br /> �. N-Y1e�"-�:w�- -i:� c�n.c,t� wc��l.f r�. tE'"T. ��v G)Se.����,.. O <br /> lO Cn�f-,u._ (. .F �,v.i.AY.- � Y�..�l� -o lT. <br /> �� �� j �/ -L'',� 2 L— � <br /> Krv� ��, rc � �rc ---- <br /> _— � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> ThP undeisigned Uw.�er/eGPlicanl hereby agrees to hold end save herm• <br /> — less thn City of Everett rrom nny eod ell dalms for dameges, cosl& <br /> ezpenses, or ceuses of qclion ihat mey eriae becauae of installetlon <br /> ���/ � and maintenence of Ihe improvement or nthei righbof•way use hereto <br /> �� �� � �� - - �_f � 3 applied for and tU�ther agrees to remove same upon notice Irom lhe <br /> �pproved fm Conslruction Dete CiC�end to i0pla public prq rty dameged thereby. <br /> i <br /> �__��� — / <br /> �l� �,-B '8'3 �✓ �. �� `.� <br /> � AL INSPECTION Date _�' � � — Da�e <br /> AppwveA as Cunsiructed 8ignnlure ol Applicant <br /> WORK AUTHORIZED BV TH S PERMIT MUST BE STARTED WITHIN <br /> everett PUBUC WOFKS DEPARTIAENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cetlar Street BE DILIGENTLY PURSUED TO COMPLETION. TH19 PERMIT MAV BE <br /> Everell,WA 982Ji CANCELLE�BV THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br /> Phone: 259-9�15 PROJECT OVER 90 DAYS DURATION. <br />