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� <br /> � .� � <br /> Date G"���� PubhcWorkaVermit• f� ���r3 i <br /> Appllcation For e�ao.o�pi., �j <br /> PUBLIC WORKS PERMIT PubreWorbPoe ' <br /> Tolal Fee S er� <br /> Leee AppL Fee PeiO S � <br /> Print or Type Only BaienceDue s���� <br /> �,T/�71 SM�Ti,% <br /> /�7�.CT//�.LAL���'�/!�E / 1 < JiL 'G <br /> yf %Sri7 c'<�i�c' f'..r///i"%�ILYI C �70��/.L-��-7�C� <br /> Owner Mailing Address City Zip Phone <br /> /�J/��T//✓L.9/�F/c'!i/J f /���� v�A;l2'1"/.7�1/f. �i'�j///;�=/���n �'/.7_ `��'a�� '7>'S�7 7 C'� <br /> Applicant Mailing Address City Zip Ph.one <br /> Describe Proposed Werk / ni�/I�ir'� /nD�F /:'//Y�' . <br /> �3 Z3 W <br /> � � <br /> Proiect Address�if known) _ <br /> Atlach four(4)copies ol plans lor proposed work- Draw to scale and note e lollowing as applicable: � � <br /> • Properry Lines • CenterPne ol street � . <br /> • Outline and dimensions ol all ezisting and • Indicale Norih <br /> proposed struclures on the lot • Show any proposed grading changes <br /> i Ezisting end proposed utilities • Show measurements � I <br /> DO NOT WRITE BELOW THIS LINE O I <br /> � PERMITCONDITIONS I <br /> t. P'�I calls lor inspection shall be made 24 hrs.in advance• phone 259•881 5. � <br /> 2. All work shall be pedormed in accordance with this permit and current Ciry ol Everett Desiyn and Construction <br /> Standards and Specificationa <br /> 3. Call Location Underc�round Service 48 hrs.before you dip.TOLL FREE NUMBER 1-800•424•5555. � � <br /> O I <br /> �w <br /> �/ <br /> O I <br /> a � <br /> � <br /> ACKNObYLEDGEMENT OF CONDITIONS <br /> The undersiyned owner/apnlicant hereby agrees to holtl and save harm• � <br /> less Ihe City ol Everelt Irom any and 29 claims lor damages, costs, � <br /> � - ezpenses, or causes of action that may arise because ol installation <br /> ���� . � �� /���� and maintenance ol Ihe improvement or other righ4ol-way use hereto <br /> applied lor and turther agrees to remove same upon nolice irom the I <br /> Approved�or�onstruction Date Ci�y and to replace public properry damaged thereby. � <br /> � --� �— 7��� I <br /> 511Ph I'NSPECTIQN Date ,��G � 7P,� � <br /> Approved as Conslructed Signature ol Applicant � Date <br /> everett PUOLIC WORY.S DEPARTMENT WORK AUTHORIZE 8 THIS MIT MUST BE STAFTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DAT IS ISSUED AND THEREAFTER IS TO <br /> Everett. WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone: 259-8815 CANCELLED BY THE CITY UPON ANY STOPPA�E OF WORK ON THIS J <br /> PROJECT OVER 90 DAYS DURATION. <br /> 1 <br /> � <br />