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Date � �� PUCtic Works Pmmh e �(n �(n V <br /> AppliCa�iOn FOf eiep Oept.• <br /> PUBLIC WORKS PERMIT PuOTolalFs`°° : <br /> Les�ApD�Fee PeiE s <br /> > OO <br /> Belence Due s "'� �— <br /> Print or Type Only <br /> SANfdtl7 �iC �EKNEY P7a�- VtSTA2AA4A �vext�" WI9 4e1oY �37-���7�rt�-2�2� <br /> Owner MaiFng Addre�s City Zip Phone <br /> �'A r��- <br /> Applicant Mailing Address City 2ip Phone <br /> Describe Proposed Work �PANA ExIS7(NG GA2 GoT <br /> W <br /> Pro�ect Address(If known) 2-�� — �'� O � <br /> Atlach four(4)copies of plans for proposed work•Draw to scale and note the lollowing as applicable: � <br /> • Property lines • Centerline of street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed structures on the Iot • Show any proposed grading changes <br /> � Ezieting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS IINE O <br /> PERMlT CONDITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance-4hone 259•881 5. � <br /> 2. All work shall be performed in accordance with this permit and curreM City of Everett Design and Construction <br /> Standards and Specitications. <br /> 3. Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 7•800•424-5555. � <br /> y T 6�E I�ONSi2UL��F� �E,e s E,/�� - �EC�+�/.izE�/1�Gr✓rS O <br /> �7�c�le . <br /> -S �o c3� Co.vsT,eUc•r�o P�-,e F>'r'.',�'���,o PLA�d-s � <br /> or9rF,o z-�s-�� � <br /> � <br /> a <br /> AGKtJOWLEDGGMENT OF CONDITIONS <br /> The undersigned owner/applican�hereby agrees lo hold and save harm- <br /> , less the City ol Everetl Irom any and all claims for damages, cosls. <br /> ezpensrs, or causes ol action that may arise because of instaltation <br /> � �� and maintenance ol the improvemenl or other iight-obway use hereto <br /> applied for and further agrees to remove same upon notice irom the <br /> Appr ed or C ruc � Date City and to replace public property damaged thereby. <br /> J _��� —^ <br /> FI SP CTION Date - <br /> Approved as Constructed Signature of Applic nt Date <br /> everett PUBLIC WORKS DEPARTMENT WORY, AUTHORI2ED BY THIS PERMI U5T BE STAfiTED WITHIN <br /> � 3200 Cedar Sireet 180 UAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,`NA 98207 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Phone: 259-8815 CANGELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAVS DURATION. <br />