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� <br /> . -- � <br /> � <br /> �� � Date_�G3(Q'� _ <br /> PueLc Wo�he Perm`n•_�J/ <br /> �y�! y ApPlication For d��g DeO��•�]/ ��I:'J�_ <br /> C PUBLIC WORKS PERMIT <br /> H C �' Pubbc 1YmM5 Fce � <br /> HzN <br /> � � ioinivee 5 <br /> �� � tess Anu� fee Px�a S I <br /> 47 y H Print or Type Only oa�r�«o�� 5 _ <br /> o� � �rr-�,�� r-�it��r�nm l��cn �Y< � �7ni��Il��� ����zi��i� r�� ��l�l-1�9� <br /> y� �y Owner Mailmg Add ess �i� ' <br /> Mi O ' one <br /> �` " �i��lio �l1�1n21� �� � + , <br /> zH� <br /> !H AnPlicant Mailinq Address City Lp Phonc <br /> i <br /> Chi H !� "1 1�.� �J <br /> O y H Describc Proposed Work �\�,� ( ��7��- FiC-1��/L� <br /> �� y <br /> HON <br /> -- --���,� - �W W <br /> p -� " Proiecl Aadress�if known� �� V. _ � <br /> c �� Altach four�4)coples ol plans br proposed work� Draw to scaie and note ihe lo�lowing as apPllcable: <br /> � <br /> • Property Lines • Centerline of streel � <br /> • Outline and dimensions ol all existing and • Intlicale North <br /> proposed strucNres on Ihe lot O Show any proposed c�ratling changes � <br /> • Exlsiin9 anU proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE � <br /> i ; PERMITCONDITIONS O <br /> 1.All calls lor inspeclion shall be made 24 hrs.in advance•phone 259•8610. � <br /> 2.All work shall be pertormed in accordance with thir permi!antl current City of Everett Design and Construction <br /> '�' Standards and Specilications. <br /> 3.Call Location Underground Service 48 hrs.6elore you dig.TOLL FREE NUMBER 1-800-424•5555. � � <br /> 1�' <br /> I"1 � ��- � <br /> 1_I � <br /> �_� �z- 6-g� � <br /> 1�1 � <br /> ►:s a <br /> s� <br /> �� ACKNOWLEDGEMENT OF CONDITIONS <br /> ' _ The untlersigned owner/applicant here6y agrees to holtl an6 save harm� <br /> Iess the Ci1y ol Everelt irom any and all claims lor damages, costs. <br /> - - expenses, or causes ol aaion that may arise because ol installation <br /> and maintenance ot ihe improvemenl or olher righ4ol-way use hereto <br /> applied lor and lurther a rees to remove same u on notice Irom Ihe <br /> Approved lor Construction �ate City and to replace public9pwperry Aamaged thereby. <br /> FINAL INSPECTION Date <br /> Appwvea as Constructed Signature ol Apphcant Date <br /> everelt PUBLIC WORKS DEPARTMENT �✓ORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED 1NITHIN <br /> � 3200CetlarSlreet 180 DAl'S OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Eeerei�,WA 98201 BE DILIGENTLV PURSUED 70 COMPLETION. THIS PERMIT AtAY BE <br /> Phone:259�8810 CANCELLED BY TFiE CITV UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAVS DURATION. <br />