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Date_�'j.��'��� ����J7 <br /> PuLI¢WmMs Perm���—` ��—� <br /> ) <br /> nnPlication For eieo-oepi.. <br /> a=UBLIC WORKS PERMIT F,bOclYorkaFee <br /> .o�a�F�e s_ <br /> Less ApPI Fee Pa�a S <br /> Print or Ty;�e Only Naiana0ve S <br /> ��CL4'l�t�,�7'�I �''r►'�i � �• � �x C ����"l� I ��S-� <br /> Owner ' M ling Address Cily l Zip Phone <br /> � <br /> l��crr l=r��cf ��G, rl I Av� 1�1� ,�1 � �(�i I l� �°���"1 r � <br /> Flpplicant Mailmg Address City Z Phone ����-v�� <br /> otf <br /> Describe Proposed Work �� � ����� _ <br /> v <br /> `��� , 1^ ' p W <br /> Projecl Address(if knownl � �� �r � �(_nJC f /,�+� � <br /> Attach fou�(4) copies ol plans for proposed work- Draw to scele and note Ihe follo :wfj as applicable: � <br /> • Property Lines • Centerline of sireet � <br /> • Ou�line and dimensions of all existing and • Indicale North <br /> proposed siructures on the lol • Show any proposed grading chanpes <br /> • En�sting and proposed utilities • Show meacurements � <br /> DO NOT WRITE BFLOW THIS LINE � <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 wilh ihis permit ano current City of Everelt Design and Construclion <br /> �;andards anA Specilications. <br /> 3. Call Location Underground Service 48 h�s. before you dig.TOLL FREE NUMBER 1-800-4:4-5555. � <br /> f� �^: � ;-;.. _ �. _ O <br /> �/�a/C G�Ci�.Lti � „�y�:;T/z!T ��' -.�����;/'r� �;�0-c`l':' <br /> i .• i <br /> % i -/: � <br /> )_... <br /> i <br /> � <br /> O <br /> � <br /> ACKNUWLFDGE�1EN7 OF CONDITIONS <br /> _^ _ _ The unCarsigned owoevapp!iC&nl hereby agrees to hold and save harm- <br /> Iess the City of Everett fron� any 2nd all clai:ns lor damages, costs. <br /> expenses, or causes ot action that may arise because of installation <br /> a�id maintenance of the improvement or other right-ol•way use hereto <br /> a;.plied for and lurther agrees to remove sare,e unon nolice from the <br /> Approved for Construction �e�e ��ry and to replace public Froperty damaged thureby. <br /> — I / ^I �� <br /> FINAL INSPECTION pa�e � ' ✓ ' � ;/1 �, ` <br /> ApProved as Constructed Signature of Applicant � Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMiT MUST BE STARTED WITNIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS I:iSUED AND THEREAFTER IS TO <br /> Everett WA 98201 BE DILIGENTLY PURSUED TO COR'PLETION. THIS PERMIT MAY BE <br /> Phone: 259-8815 GANCELLED BY THE CITY UPON ANY STGPPAGE OF WORK ON THIS <br /> I PROJECT OVER 90 DAYS DURATIO�. <br />