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�� � <br /> Date� PuEbc Wo�kn Pnrmit• <br /> B�ap.Deot• �d,T_� <br /> Application For � <br /> PUBLIC WORKS PERMIT PuOTotNFea�aB S <br /> Leaa ADO�fae PeiE s <br /> Belence Due S <br /> Print or Type Only <br /> �� 11�����, S�l�?��l/.� /.5'k'ki� ,��i'���i' �7.r35 �S7 ��.�6 <br /> wner <br /> � Mailina Address i�y Zip Phone <br /> � <br /> f��� ���/ ��� ����� .��-��- ��.�� 25� <br /> Applicant <br /> MaJing Address City Zip Phone <br /> /' ��_�.�h /',�,q fr� G1�e c3 S��' — <br /> Describe Proposed Work � <br /> W <br /> Proiect Address(if known) - � � <br /> � <br /> Attach four(4)copies of plans lor proposed work• Draw to scale an note the followi^q as apPlicable: � <br /> • ProPerty Lires � Centerline ol street <br /> • Outline and di�vensions of all existing and • Indicate North <br /> proposed struUures on Ihe lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremenis M <br /> W <br /> DO NOT WRIiE BELOW THIS LINE O <br /> PERMIT CONDITI6NS � <br /> t. All calls for inspection shall be made 24 iirs. in advance- phone 259-881 5. <br /> 2. All work shall be pertormed in accordance wilh Ihis permi� and current City ol Everet� Design and Construction <br /> Standards nnd Specifications. � <br /> � 3. Call Location Underground Service 48 hrs. before you dig,TOLL FREE NUMBER 1-800•424•5555. <br /> O <br /> IUO PUdG�� GriO,�,�S f F�mi�i ��9�/..�'�/.� <br /> �� ��s��� G� <br /> O <br /> a <br /> ACKNOWLE�GEMENT OF CONDITIONS <br /> The undersigned owner/applicanl hereby agrees to hold and save harm- <br /> less ihe Cily ot Everett from any and all claims for damages, costs, <br /> expenses, or causes of action that may arise because of in;tallation <br /> and maintenance ol Ihe improvement or other right-ol-way use hereto <br /> applied lor and lurther agrees to remove same upon noticc Ircm lhe <br /> Approved for Construction Da1e City and to replaca public property damaged Ihereby. <br /> FINAL INSPECTION Date Date <br /> Approved as Constructed Signalure of Applicant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everelt PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERt�11T IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sireet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY TH[CITY UPON ANY STOPPAGE OF WGRK ON THIS <br /> Phone: 259-8875 PRO.iECT OVER 30 DAYS DURA710N. <br />