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Date j�.R Y Pu01ic Worhs Par t♦ ' '�U� <br /> A�plication For eie9.ooat•.� '�'�� <br /> PUBLIC WORKS PERMIT PubTolevFeeFeB : <br /> Lesa PpD�Fee PeIE s <br /> Print or Type Only Betan<e Du. S 2l>Ol7 <br /> �a Y�9 <br /> ��7`cve. �r��;P�e� l��i����. d��a .�v�- �-9 - i�ryr <br /> Owner Malling Address City Zip Phone <br /> \���1 � <br /> Applicant Mniling Address Ciry 2ip Phone <br /> z <br /> I 0 <br /> nrE UC n �� h Oc1J E � <br /> Describe ProposeJ Wc�K - � <br /> m <br /> � i <br /> � � I <br /> W � � <br /> �,_ <br /> � 1 � m <br /> Pruiect Address(il known) . � � X / � � <br /> r*, o <br /> Attach lour(4) copies ol plans for proposed work• Draw to scale and note the following as applicable: � ,�� � <br /> • Property Lines � Centerline ol street � 3 <br /> • Outline and dimensions ol all existing and • Indicate North N = � � <br /> proposed structures onthelot • Show any proposed groding chenges m <br /> • Existing and proposed utilities � Show measurements � c Z ; <br /> DO NOT WRITE BELOW THIS LINE O � = I <br /> PERMIT CONDITIONS � �' <br /> 1 <br /> � <br /> 1. All calls for inspection shall be made 24 hrs. in advance-phone 259•881 5. o z <br /> 2. All werk shall be performed in acwrdance with this permit and current City of Everett Design and Construction � � 3 <br /> Standards and Specifications. —� m <br /> 3. Call Locetion Unde�{7round Servica 4B hrs.before you dig.TOLL FpEE NUMBER 1•800•424•5.ri55. � m N <br /> or <br /> O c� m <br /> C N <br /> 3 N <br /> m <br /> z c� <br /> .� m <br /> � a <br /> A <br /> � � <br /> 2 <br /> D <br /> 2 <br /> O � <br /> � <br /> � N <br /> Z <br /> r\rr O <br /> V/ •-�• <br /> �� � <br /> `I m <br /> %y� ACKNOWLEDGEMENTOFCONDITIONS <br /> �� The undersigned owner/applicant hereby agrees lo hold and save harm� � <br /> less Ihe City of Everett irom any and all claims for damegos, costs, <br /> ,7 czpensos, or causes oi action that may arise because ol instaltatlon <br /> �� /a"7� �p �O 8� and maintenance of the improvement or other right-of-way use hereto , <br /> Approved lor onstruction applied lor and further ��re ,� to remcve same upon noUco from lhe <br /> �—� a1e City and to_ ¢p!ace UutrN� operty damaged thereby. <br /> .� � / � , � .. � <br /> t-� �� ` ' <br /> FINAL S C710N ate `-� (^I1 ���� 1� ' �O/�)�{� <br /> Apprmed cis Constructe� , Signature of Applicanl� Date <br /> everett PUBI�C WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT �AUST SE STAHTED WITHIN <br /> � 3200CedarSlreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEFEAFTER IS TO <br /> Everett,WA 98207 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone: 259•8815 CANCEILED OY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />