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,� s o � <br /> Publ¢works Pe�mll• <br /> Date <br /> BIE9�DeO��• <br /> Applicelion For <br /> PUBLIC WORKS PERMIT PobiicWorMFee <br /> Tot�l Fee f ,n <br /> � Le�s Apo�Fee PNE f--�� <br /> B�Imce Oue f �� '_' � <br /> Print or Type Only �6 D/.3 <br /> o.25'aZ - a/Slr <br /> � /-� ��e��7`c�r� �3/ �r��+��� .,�P,��7� ��/ <br /> Owner <br /> Mailinq Address City LP Phone <br /> � f�i?�4 Co.�,r� /�r� Jax J�?9`�1 �'oe�eT� �,�� - 36 6 7 <br /> — Mailing Address City 2ip Phone <br /> ApC�icaM <br /> z <br /> �� ���--�— � <br /> � <br /> Describe Proposed Work � <br /> m <br /> W � �' <br /> .. .� <br /> ��i� � _ <br /> m <br /> Prolect Address(if known) c v I <br /> � mo <br /> Attach four(4)copies o�plane lor proposed work• Draw to scale and note e ollowing as applicable� � c� � <br /> • PropertY Lines • Cente�line of street o 3 <br /> • Outline and dimensions of all existing and • Indiwte North � Z I <br /> • Show any proposed greding changes = 1 <br /> proposed atructures on the lot � Show measurements M m � <br /> • Exi6tinB and proposed ulililies W C z <br /> DO NOT WRITE BELOW THIS LINE O � _ <br /> —� N <br /> PERMIT CONDITIONS � "� <br /> � <br /> 7, All calls for inspection shall be made 24 hrs. in advance• phone 259•881 5. p 3 <br /> 2, Atl work shell be performed in acwrdance with this permit and current City ot Everett Design and Construction <br /> Stendarde and Specifications. � m <br /> 3. Call Location Undergroun: Service 48 hrs. before you dig.TOLL FREE NUMBEH 1•800•424•5555. � m N <br /> � ���/�.s �/��� �-8 -8s O o � <br /> ��� ���� � � <br /> m �' <br /> z c� <br /> � � r <br /> m <br /> a <br /> � A <br /> 1 <br /> 2 <br /> O p <br /> z <br /> --1 <br /> a � <br /> � <br /> Z <br /> 0 <br /> � <br /> � <br /> � <br /> m <br /> AGKIJOWLEDGEMENT OF COND!TIONS <br /> The��ndersigned owner/applicant hereby agrees to hold and save harm� <br /> iess Ihe City of Everelt Irom any and all claims tor damages, costs, <br /> �� �j�� expenses, or causeslol action �hat may ariso 6ecause ol installation <br /> and maintenance o��the improvemenl or other right�ot-way use hereto <br /> �� applied for and tu�her agrees to remove same upon nolice from the <br /> Apof[lvedlor�ons�tion ! Date Cit and to replace public property damaged thereby. <br /> �— � ��� �3� -� y _ �Z -�s <br /> � SPECTION Date Date <br /> Approved as Constructed Signature ol Applicant <br /> WORK AUTHORIZED BY THIS PERMI MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DAIE PERMIT IS ISSUE AND THEREAFTER IS TO <br /> � 3200 Cedar Slreet BE DILIGENTLY PURSUED TO COMPIETION.THIS PENMIT MAY BC- <br /> Everetl,WA 98207 CANCELLED BY THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 PROJECT OVER 90 DAYS DURATION. <br />� <br />� <br />.` - <br />