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DateJSL_1�QQ � <br />PUB�IC <br />� <br />Print or Type Gnly � <br />Ownor <br />.� - �a - z� - -� <br />Applicnlion For <br />WORKS PERMIT <br />sgss�s sss� <br />����� ��� <br />A � (�L 1 M <br />Mau i � . �ny <br />i� � <br />� <br />I � m ."�. <br />Idailing Address Qty <br />Describa Proposed Work �/Q�i� v�' l <br />Prolect Address (if known) <br />Zip <br />Attach lour (4) copies ot plans lor pioposed work • Draw to scale anA note Ihe lollowing as appllcable: <br />• Property Lines <br />• Outline and dimensions ol all ezisting and <br />proposed s�ructures on Iho lot <br />• Exisling and proposed util�lies <br />i <br />li <br />Pu01¢ Worhe Per/m�i� •/ ����J�/--�� I <br />fi�dp Deo1 ��((�Je✓J�j(]�- I <br />Pu�Lc Worhs fee s II <br />Tolsl Fae <br />1 naa RoO� Fee P�id S I <br />aa�w��e o�a s ?o" � <br />• Ccnterline ol streel <br />• Indicate Norih <br />• Show any proposed gradiny r,hany�s <br />• Show measurements <br />Phane <br />PERMIT CONDITIONS <br />1. All calls for Inspoction shall be made 24 hrs. in odvanca - phone 259•ii810. <br />7.. All work shall ba peAormed in ecwrdence with ihis permit and current Ciry ol Everett Design end Construction <br />Stenderds and Specilicalions. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�;���� _►0- 24 - go <br />Appruved for Conslru ion �� Date <br />��n�/ �'" S" -� S- e i <br />FINAL INSPECTION Dnle <br />App�oved as Cunstructed <br />ev•rrt[ PUBLICWORKSDiF4RTMENT <br />� 5200 Cader Sirael <br />Everett. WA 9B2C1 <br />Fhone:259�Bfi70 <br />ACKNOWLEDGFMENT OF CONDITIONS <br />W <br />H <br />� <br />The unders�gned owneHapP�ic�nl hereby agree5 to hold ano save harm� <br />less Ihe Gty of Everetl Irom any and all claims lor damages, costs, <br />expensr;, or cnuses ol action thal may arise because ol installalion <br />and maintenance of the improvement or other righ�-ol�wey use here�o <br />aru+i�Pn ��r n.,n i��.u,�. �...00� �.. .>.��„o ��.^^ ..�on nofice irom �he <br />�� Y <br />/ / � 9 <br />Dale <br />WOHK AUTI1UfiIZED 9Y THIS PERMIT MUST BE SThRTFO WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEP IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE GTV UPON ANV ST(iPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DU(7ATION. <br />