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Date.�1L�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print orType Only <br />b <br />City 2ip <br />L._i , , T <br />roriLc Wo�ks Pa.mn • <br />6mV oeu�.• ` l J� �L�rJ <br />Pubiic WOA� Fea <br />Talel iB! s <br />Lese RpDI fee Pe�d S <br />Beience Oue S <br />Dascribe Proposed Work _��(�� %]�� V, � � X �� 1 -�p �nr� ��1'� _ <br />Project Address (if known) <br />Attach fow (4) copies ot plans for proposed work - Draw to scale <br />• Property Lines <br />• Outline and dimensions of ail existing and <br />proposed SiruCture6 on the lOt <br />• Existing and proposed utllities <br />PERMIT CONDITIONS <br />note ihe lullowing as apolicable: <br />• Centerline of street <br />• Indicate North <br />• Show any proposed gradiny chanyes <br />• $hOW fiIP2bUf0ffIQn�S <br />1. All calls for insper,tion shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work sha�l be performed in acr,ordance wi�h this permit and current City ol Everett Design and Construction <br />Slandards and Speciticalions. <br />3. Call Location Underg�ound Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />/riD fUBGiG lvo,�.�S �=�-e��� �'F�U�.c'E.�- <br />yowF�F.� � P�v�.d�,d�- ,�-.�-�- �f/ h'av� <br />SO/��E �0/1/�'F,er�/S <br />/PFQU/.eF�%. <br />�Ii30UT �<l•e.�i�/G Sf �Cc�S <br />`?1�� 7-i.� es <br />Approved br Construction Date <br />FINAL INSPECTION Date <br />Approved as Cc�structed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone: 259-8d15 <br />ACKNOWLEGGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />M <br />♦�^ <br />V♦ <br />� <br />a <br />The undersignetl owner/apP�ir,ant hereby agreesto hold and save harm- <br />less ihe Cily ol Everet� trom any and all claims for damages, costs. <br />expenses, or causes ol tction ihat may a�ise because of insfallation <br />and mainlenance ol �he improvement or other righFobway use hereto <br />app��ed for and lurther agrees to remove same upon notice irom the <br />Ciry and to replace public nrope�ty Aamaged iheieby. <br />Signature ol Appiicant Dale <br />WOflK AUTNOPIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />i3E DILIGE�ITLY PURSUED TO COMPLETION. THIS PERMIT MAY 8[ <br />CPNCELLED BY THE CITY UPON ANV STOPPAGE OF WOF;K ON THIS <br />Pi70JECT OVER 90 DAYS Dl'RATI0�1. <br />z <br />0 <br />-i <br />� <br />m <br />-i .. <br />� <br />.., � <br />�' m <br />0 <br />co <br />m o <br />n <br />0 3 <br />m <br />-i z <br />x -i <br />m <br />oz <br />c <br />� .._. <br />� � <br />< T <br />O D <br />3 <br />-i m <br />m .-� <br />� <br />0 <br />or <br />n rn <br />c in <br />3 � <br />m <br />z c� <br />�m <br />a <br />z <br />-� <br />_ <br />n <br />_ <br />-� <br />_ <br />N <br />2 <br />0 <br />� <br />� <br />