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Date O ��� � <br /> PUEi¢Worb Parmil� � <br /> Appiicalion For <br /> PUBLIC WORKS PERMIT BmpDeo� • <br /> PuEI¢Worka Fee <br /> Total F¢a S�_ <br /> Pllflf Of T � �e"+pnoiveevaia S <br /> ype Only —�_ <br /> Balance Oue $ �S�- <br /> ��i 1�-W-2D �'Y �17n �2 ,�! ,�Ci.l n <br /> Owner Maihng Address �' ��—n Q�Jz-7S ��t7o 9 4L, <br /> Ciry Zip —�—�.� <br /> Pnone <br /> �,'�S..l l-A 2� ES F�' oi 7 n 7 S Z �� Gv �N c� L,.x! <br /> Mailing Atldress ���Y ��� �� '�N`7r R9,l� <br /> Z�p Phone <br /> Desc�ibe Proposed 1Vork <br /> �-,�l,\ C c ��c� Tt� r' ��F <br /> i <br /> �— <br /> Project Address�if known) �_ � <br /> Attach four(4)copies of plans lor proposed work• Draw to scale antl note the followin � <br /> • Property Lines 9 as applicable: <br /> e Outline and dimensions ol all existing and � Centerline ol slreet � <br /> u�oposed struct�res on the lot • Indicale North � <br /> • Existing and proposed ulilities � Show any proposed yrading changes <br /> • Show measurements <br /> DO NOT WRITE BELOW THIS LINE m <br /> PERMIT CONDITIONS O <br /> t. All calls lor inspection shall be made 2q hrs. in advance• phone 259•8815. <br /> 2. All work shall be performed in accordance with this permit and currenl City o(Everett Design and Construction <br /> Staiidartls and Speci�icalions � <br /> 3. Call Location Underground Servicu 4B hrs.before you dig. TOLL FREE NUMBER 1-$00•424•SSSa. <br /> f! Lvac.� ;0 6'F Oo.iE .aE,� 9�/�,¢o�•_--o Z <br /> PC.9,c.i IJ�9r�:� �/B7 <br /> O <br /> � <br /> O1/06/E7 i<^:29Pti OOORd3553 � <br /> / � <br /> DRUW;' 835.00 � <br /> CHECI; 535.00 <br /> ACKNOWLEDGEMC-NT OF CONDITIONS <br /> The undersigned owner/applicant hereby t9rees to hold and save harm- <br /> � less the City ol Everett Irom any and al; cl�ims for damages. costs, <br /> expenses, or causes of ac�ion thal may arise because of installation <br /> y"�- % � .T �� and maintenance of the improvement or other�ighDohway use herelo <br /> �0°ed �O rudioo-- �;- pafe � applied tor and further agrees lo remove same upon notice hom the <br /> r � / % i City and to replace public property damaged thereby. <br /> � 11'li �/ � /('�') <br />�I CINSPECTON w --��/�S,LtiLC_ <br />�pprovetl:;Constructed Date _ <br /> SignatureolAU� ant <br /> everett PUBUC WORKS DEPARTMENT WORK AUTHOq12ED BY THIS PERMIT MUST fiE STARTED WITHIN <br /> � 3200CedarSireet 180 DAYS OF UATE PERMIT IS ISSUFO AND THEREAFTER IS TO <br /> Everetl,WA g8201 3E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8875 CANCELLED BV THE CITY UPON ANY STOPPAG[Of'WpRK ON THIS <br /> PROJECT OVER 90 DAYS UURATION. <br />