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�� <br />��+a�Q:: ;"_ <br /> .,. <br /> � Y: <br />� ���j(�j��`/-]'� � 89 3 y <br /> Date�f..il.l � PuOhcWorkaPer <br /> Applicat�n For eieo.oapi., __ <br /> PUBLIC WOF�KS PERMIT P°b°�W°�k,Fee r-�-:_ <br /> 0 <br /> Te�a�Fee s <br /> �essnnui Fo�r��a S ttt��� f <br /> o '� � � r'� oaiance Due S �� <br /> Print or Type Only z � °� °: "� `` — <br /> r(�-i .�+ o; r� in o <br /> O O� P C�1 �O W <br /> tl1 ai �O � Q. <br /> ��� �� � ���� ��G (�� �� �� A �1 <br /> Owner Mai�g A RSy � ��� � City Zip Phone <br /> �O Op F- � 1— IJ <br /> \ Yk � d2 � U <br /> � G.�-� ��_ 3��� <br /> Applicant Mailing Address Ciry Zip phone <br /> De�cribe Proposed Work _ .--���i� �Jl�-J� I I I C—%� l--c <br /> W <br /> Proiecl Adtlress(il known) _ ��2c � _�AG�t//J(/ � <br /> Attach lour(4)copies of plans for proposed work•Draw lo scale and�ole the lollowing as applicable: � <br /> • Property Lines • Centerlina ol street � <br /> • Outline and dimensions ol all existing and • Indicate Norih <br /> proposed slructures on�he lot • ShoH�any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMITCONDITIONS <br /> 1.All calis for inspection shall be made 24 hrs.in advence•phone 259•8810. � <br /> 2.All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMUER 7•S00•424•5555. � <br /> ,�, � �i�,.���1� �,�� �� �g -� � 0 <br /> H <br /> � <br /> O <br /> ���;���� f.�.�� r ,tr a <br /> . � � . <br />� ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicanl hereby agrees to hold and save harm� <br /> less the Cily of Everett from any and all claims for damages, cos(s, <br /> � expenses, or causes ol action thal may arise because of installatinn <br /> � ' Q J�v . 9 and maintenance of ihe improvement or other ri�ht-ol-way use hereto <br /> � applied lor and lurther ag�ees lo remove same upon notice Irom itie <br /> Ap ved f r Con t ctio � / � Date City and to replace public property damaged thereby. <br /> /Zl�"Q�/`'' U/o -�o � <br /> FINAL INS�ECTION Da�^ <br /> Approved as Constructed Signature ol Applicant Date <br /> everett PUBLICWORKSDEPARTMENT WORK AUTtiORIZCD BY T 1 PER IT MU T BE STARTED WITHIN <br /> � 3200CedorSireet 1A0 DAYS OF DATE PER IS ISSUED ND THEREAFTER IS TO <br /> Everett.WA 98201 BE DILIGENTLY PURSUED TO COMPLETI N. THIS PERMIT MAV BE <br /> Phone:259-9870 CANCELLED BY THE CITY UPON AN'(STO PAGE OF WORK ON THIS <br /> IPROJECT OVER 90 DAYS DURD.TION. <br /> :��yy- <br /> J <br />