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, Date �O �/ 3 PuClic WorluPermn t u � a' 3 S <br /> � Application For emo.oePu � <br /> PUBLIC WORKS PERMIT PuOTotalFeeFee S -�. o � <br />, � Leat ApOL Fee PeiE S <br /> Balence Oue S �� �� <br /> Print or Type Only <br /> � � ( <br /> r <br /> :�I Q���tev� ���(�Gu�.� ��'( 5 ���f •�'� ��2�� oZs 2- 3� I <br />� Owner Maiiing Address City Zip Phone <br /> � � S, '` " � ��(��o "�f <br /> p�licant Mailing Address City Zip Phone <br />� n � <br /> IDescribe Proposed Work�` �rJ�� » " ""� • "� ���C�—� <br /> I <br />' <br />� W <br /> Project Address(if known) � � <br /> Attach lour(4) copies of plans for proposed work- Draw to sc e and note the following as applicable: � <br /> • Property Lines • Centerline ot slreet � <br /> • Outllne and dimensions ol all existing and • Indicate North <br /> proposed s:ructures on the lot • Show any proposed grad!ng changes <br /> • Existln6 and proposed utilities • Show measurements /M <br /> ��� , W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance• phone 259•881 5. � <br /> 2. All work shall be performed in accordance with this permit and current City of Everett Design and Construclion <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 hrs. belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> y �o,�,�F�T s��,� �a,d �x,s:,�G ���.s .�,��y" � <br /> sc2��'�2_ C9.!'T /.(�'o�J a/�fBE.e .�cr��.wnJG', <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The unde:signed owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everett trom any and all claims for damages, costs, <br /> expenses, or causes ot action ihat may arise because of installation <br /> � � ��� and maintenance of Ihe improvement or other right-ol•way use he�eto <br /> applied for and further agrees to remove same upon notice irom the <br /> Appr ved lor Cons tion �ate City and 10 replace public property damaged thereby. <br /> � �� /- 1-0 � J=y <br /> � � � <br /> ; / <br /> F AL��NSPECTION Ds'te ?--�' � ��ti <<i p"7 ���'��/�`� <br /> Approved as Construcied Signature of Applicant � <br /> everett PUBLIC WORKS DEPARTMENT WOFK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarSlreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everetl,WA 98207 BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone:259-8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS � <br /> PROJECT OVER 90 DAYS DURATION. . <br /> i <br /> � <br /> 1 <br /> II � <br /> t <br />