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Date..(Q _i1Z�� <br />Appiicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Oniy <br />Cily Zip <br />y4 <br />Applicant <br />Describe Pioposed Work _J�iy�.J ��Q � ry���EO�„� <br />Pro�ect Addresa �If known) <br />Attach lour (4) copies of plans lor proposed work • Draw to scale and note the following as applicable: <br />• Praperty Lines <br />• Outllne and dimensions of all existing and <br />proposed stnictures on tho lot <br />• Existing and propose:, utillties <br />� <br />Pu�iic Wor�s Perm.t • �� G/� <br />Bieg DxOt � �y—s�— <br />Puni�c wode Fon $ <br />Total Fea — <br />Leaa RC41 Fea PeiE S <br />$ �) �7 C.�Q <br />Belancn Oue �� <br />• Cantedine of siroet <br />• Indicate NOAh <br />• Show any p�oposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All cails for inspectlon shall be mede ?4 hrs. in zdvence • phone'4��Ts �J�(— �'FI (;,) � <br />2. All work shpll be performetl in accordance with this permit and current City ol Everett Design a�d Consiruction <br />Slanderds und Specifications. <br />3. Call Location Untlergrauntl Service 4B hrs. before you dig. TOLL FREE NUMBEH 1•800•424•5555. <br />I,(/STAG L STj,c'fH� t C� E:�w -�d.— . Fo.c• S Ewc:c° Si-ciL? <br />fT f�•eos'E�:� Li,r/E �� 6LE�.� ���T F,�,cc s t�lir�rn/ <br />/�!a✓ED 1>�'.uEcJ�;�� .H.�E.°, USf C./Tf/ ST.9NDF<�p '�L^OS� - <br />Ch'11..'lN�� <br />Appraved es Construcled `-' U <br />everett PUELIC WORKS DEPARTMENT <br />� 3200 Cedar Slreat <br />Everelt, WA 98201 <br />Phone: 259-bB-Lb PSyp <br />ACKNOWLEDGEMENT OF COND�TIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owiier/applicant hereby aB�ees �o hold and save herm- <br />less the Cily of Everett irom any and all claims lor damages, costs, <br />ezpenses, or causes of action that may arise because of Inatallation <br />and ma�ntenance of the improvement cr other right-obway use hereto <br />applied lor end further agrees to removc same uoon nolics Irom tho <br />City d tc rnplace b�c property damaged thereby. <br />-/0•� 7 <br />ignature ol Applicant Uate <br />WORK HUTHORI7ED BY THIS PERMIT MUST BE STARTFD WITHIN <br />1B0 OAYS OF DATE PERMIT IS ISSUED AND THEREAFTER I5 TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BF <br />CANCELLED 81' THE CITY UPUN ANY S70PPAGE OF WORK ON 7HIS <br />PROJECT UVER 90 DAYS GURATION. <br />