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il <br /> Date� i � PUEbc Wo�k�Perm�n+��� <br />� Application For ema orm.•�[L <br /> PUBLIC WORKS PERMIT Poei¢WOMaFee — <br /> Tote�fen f <br /> LeseRpP� FeePeiU s <br /> Print or Type Only Be!�nteDue f _— <br /> ��CYhh C0. . ��.�� l � �e —IZ.D. ��'_ `,� .�i/P/OY7�— �c�Zd'-� ,3.3 7—���� <br /> Owner MadmgAdd:ess Ciry Zip Phone <br /> 1�h�hPl�,wTTP�� .�Pni,i ,A.y f�0 B�K�7—�e/ P��n�F/a �a.�� a�7 <br /> Ap I' ant Mailing Atld�ess Cdy Lp phonr, <br /> Describe Proposed Work SQ+Y�e-�// � /��n 7y n N 6. <br />� Project Adarecs lif known) 7L',1 � ,�n � <br />� Attach lour 14)copies of plan;for proposed work• Draw tu scale and note the lollowing as applicable: � <br />� • PropeAy Lines • Centerline ol ctreet � <br /> • Outline and dimensions of all existing and • Indicele North <br /> prnposed structures on ihe lot • Show any proposed grading changes <br /> � Ezistinp and proposed utilities • Show measuremenis � � <br /> DO NOT WRITE BELOW THIS LINE O I <br /> I <br />� PEFMITCONDITIONS <br /> 1.All cells tor inspection shall be made 24 hrs.in advance-phone 259•8$1 O. � <br /> 2.All work shell be performed in acwrdance wilh this Germit and current City of Everett Design and Construction <br /> Standards and Specilications. <br /> 3.Catl Location Underground Service 48 hrs.befora you dig,TOLL FREE NUMBpR 1•800-424-5555. � <br /> �/o��' �� � <br /> ��� �,�s �. <br /> � <br /> 0 <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br />_ The.mdersiyned ownedapplicant hereby agrees lo hold and save harm� <br /> less ihe City of Everetl Irom an� and all claims lor damages, costs. <br /> ennenses, or causes of action ihat may a�ise bec2use el installation <br /> and mainlenance of ihe Imp�ovement or other ngln�of-way use herelo <br /> AOProved lor Consiruction applied tor and Further agrees to �emove same upnn noace Irorr the <br /> Date City and to replace pubGc property damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Consiructed Signature of Applicant Date <br /> everetl PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PEpM1T MUST BE STAfiTE!J WITHIN <br /> � 3200CetlarStreet 180 DAVS Gr DAT[ PERMIT 13 ISSUED AND THEREAFTER IS TO <br /> Everetl,WA 98207 BE DILIGEMTIY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259-8810 CANCELLED BY THE CiTY UPON ANY S70PPAGG OF WORK ON THIS <br /> PROJ[CT OVE!i JO DAVS DURATION. <br />