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Date�l'� —� 7 <br />App'ication For <br />PUBLIC W�RKS PERMIT <br />Print or Type Only <br />"�lnn Koe.��a _ ZI�_3�`� <br />Owne� M.dling A�!dres: <br />a„oi,c wa�ws r���m�pi . > <br />Biae Deni + _�c �Z <br />Publm Wo�ks Fee S <br />Tolal Fea <br />Lev Appl F!B �eiE � <br />Baiance Due 5 <br />Zip Phone <br />5 uw-� <br />AfPlicant MailingAddre�s City Zip Phone <br />Describe Proposod Work �'1-01� G(�0 {.N_ e!' ��a / k foa h 1 f�� S�% <br />�•��ert Address (if known) � � � L � - � � *h cf.0 � -�% <br />Attach lour (4) copies of plans lor proposed work • Draw to sca�e and note tl�.e fo�lowinq ns applicable: <br />• Property Lines <br />• Outllne and dimensions ol all existiny and <br />prop000d etructures on the lot <br />• Ex�sting and Proposed ulili�ies <br />PEFM!T CONDIT�ONS <br />� Cenferiine o! sireU <br />• Indicate Ncrth <br />• Shuw any proposed grading chanqes <br />• Show measurements <br />1. All calls loi inspection shall be made 24 hrs. �n advance - phone 259•8815. <br />2. Alt work shell b� pedormed in accordnnce v:�th t�is permil and current City of Everett Desipn and Construction <br />Standards and Specilicaliona <br />3. Call Location Underground Service 48 his �e'ore you dig. TOLL PREE NUMBER 1•800•424•5555. <br />/UO P/J,f�G/G CJo2,eS' /a��,�iT ,��G�U/�E,� <br />Approved for Constructlon <br />FINAL iNSPECTION <br />Approved ae Constr�cted <br />everett PUBI.IC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Evcrett, WA 98201 <br />Phono: 259-8815 <br />lo�z2� �7 <br />���� <br />ACKNOWLEDGEMENT OF CONDITlONS <br />W <br />� <br />� <br />F" <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save ha•m- <br />' less the Ciry oi Everetl from any and all claims lor damages, ccsts, <br />— I expenses, or cause� ol action that may arise because of inste!tation <br />and maintananca of the hnprovement or athe� rigM•of-way use hereto <br />applied lor and furiher agroes to remove same up,n notice liom the <br />�ate City and to replace public property damaged there��y. <br />Dute — <br />S�pnelure ol Applicant Dnte <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTi=D WITHIN <br />180 �AYS OF DATE PERMIT IS ISSUED AND THEREAF'i ER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERM�T MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />