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Dates��s a���,�wo,�s�e�m��. 8�°�— <br /> Application For eiea oeo� • �/U <br /> PUBLIC WORKS PEF�MIT � ^� �� �u01�cWo�kfFee — <br /> ��, Total Fee S <br /> lesa Aoa�.Fee PeW $ <br /> Print or Type Only BalanceD�e � /� 7� <br /> C�ov� �0 9 �!��` ��s-e C�. �1 `3-�7 ? -y/Y y <br /> Owner Mailing Address City Zip phone <br /> \�c�-,..� <br /> Apolicant Mailing Address Cily Zip Phone <br /> Describe Proposed Work <br /> � � � �� <br /> ' <br /> Project Address�il known) � ���7 �-r� _ � <br /> .��� �- � <br /> I Attach lour(4)copies of plans for proposed work- Draw to scale and note the tollowi.�g as a,plicable: � <br />! w property Lines • Centerline ot street � <br />� • Outline and dimensions of all existing and • Indicate Ncrih <br /> proposed structures on the lol • Show uny proposed�rading changes <br /> i n ^xisting dnd proposed utilitios • Show mezsuremenis � <br />�I DO NOT WRITE BELOW THIS LINE O <br /> I PERMIT CONDITIONS <br /> 1. All calls lo�inspection shall be made 24 hrs. in advance-phone 259-881$. � <br />� 2. All work shall be pertormed in accordance wilh this permit and current City ol Everett Desi4in and Consiruction <br />� Standards and Specifications. <br />� 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREF NUMBER 1•f300•424•5555. � <br /> II q. �' ������/�s <br /> 0 <br /> F— <br /> � <br /> 0 <br /> a <br /> /1CKNOWLEDGEMC-NT OF CONDITIONS <br /> The undersigned owne�/applicaN hereby agrees to hold and save hann- <br /> less the City of Everett irom any and all claims lor damagea costs, <br /> '/ expenses, or causes ol action that may arise because of inslallation <br /> ���_Gj/ and maintenance of Ihe improvement or olher right�of�way use herelo <br /> `—S—�%�-� applied lor and further agrees to remove same upon notice Irom the <br /> Approved or Construdion // Date ity and to rep� ce public property damaged thereby. <br /> ��t"Y � I` Z 2-/"� ♦ 1 • <br /> ! <br /> FINAL INSPECTION � Date � �� _ ��'_ <br /> Approved as Constructed Signat e Ap c nt Date <br /> everett PUBLIC WORKS DEPARTMENT WORf AUTI OR D �Y THIS PERMIT MUST BE STARTEC WITHIN <br /> � 3200CedarSlreet 180 YS F DATE PEHMIT IS ISSUED AM1D THEREAFTEF IS TO <br /> EveretL WA 98201 BE DI IG tLY PURSJED TO COMPLETION. THI� PEFknT �1AV BE <br /> Phonc: 259�II815 CANCE EO 9Y THE CITY UPON ANY STOPPAGE CF lvG1;�:ON THIS <br /> PROJECT O�rH 90 DAYS DURATION. <br />