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I <br />r �� <br />Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />helic waft Plrrft I y to y' <br />oleo Door. -570 <br />ftblic Tots Fft Fee ` o-t 0. U (7 <br />LIU APpt Fn P84 i <br />Btitncl Du, t�ri ' 0 <br />707,R6 <br />Owner Mailing Address City Zip Phone <br />-eyes, 4`�C)rLjer a911, ia4ti st- Ek- %,201 21'j9-6M- <br />Applicant Mailing Address Cityl _ _L Zip Phone <br />Describe Proposed Work 101&Cf IRA YP�1 �.YIT I �t I 60'ragir- <br />Project Address (if known) .41 �i�QC.�n .YCIi f_t'-'') E�iCrC I ��a0i Fm <br />At',ach four (4) copies of plans for proposed work -Draw to scale and note the following as applicable: • Property Lines • Centerline of street• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hra in advance' phone 259.8815. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Spncirications. <br />3. Cell' ocation Underground Service 48 his before you dig. TOLL FREE NUMBER 1.800-424.5555. z <br />0 <br />Approved for Construction Date <br />FINAL INSPECTION Dfite <br />Approved as Constructed <br />eleveFett PUBLIC WORKS DEPARTMFNT <br />3200 Cedar Stres, <br />Everett, WA 98201 <br />Phone: 259 8815 <br />L <br />U) <br />0 <br />am <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damager, costs, <br />expenses, or causes of action that may arise because of cstallatlon <br />and maintenance of the improvement or other righl•ot-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature 6f Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />dE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />FF' <br />.. <br />J <br />