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1 <br /> � �� <br /> �-6=�3 $ J <br /> Date Public Worb Permii s � � / � <br /> Application For emo.oeo+�• <br /> PUBLIC WORKS pERMIT PubTotelFeeFee s ��.�,�> <br /> Less Aoo�Pee Paia S �Q'� <br /> Balence Due S —� �— � <br /> ' Print or Type Only � �3�66 <br />� CHEVRON USA INC. P.O. Box 220 Seattle 4!A 98111 628-5222 <br />� Owner MailingAddress City 2ip Phone <br /> Bruce J. Fittere_r P.O. Box 220 Seattle IdA 98111 628-5222 <br /> Applican� Mailing Address Cily Zip Pho�e <br /> I� DescribePropoaedWork Locate 6' x 12' prefabricated steel pay booth at existing pump <br /> isiand. <br /> �role��Address(il known) � <br /> � <br /> Attach lour(4)copies ol plans for proposed work•Draw to scale and note the following as applicable: � <br /> • Property Lines • Centerline ol street � <br />� � Outline and dimensions of all exic�ting and • Indicate North <br /> proposed structures on the lot • Show any propoaed grading changes <br /> • Existing and proposed utilities • Show measuremenls � <br />� DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> i. All calls for inspection shall be made 24 hrs. in advance• phone 259•881 5. � <br />. 2. All work shall be performed in accordance with this permit and currenl City of Everett Design and Construction <br /> Standards and Specilicztions <br /> 3. Call Location Underground Service 48 hrs. belore you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> � C .L�7 . �1b Lj� ���7l7LG��r<y qti� c:�(��v ..��� �J <br /> (� 1 v I � <br /> i (� w10lic_ ( l/� u�lcs --li7s�c�_�a/ c��1-Gr � beivt <br /> ' 10� C o w-�-rn-c�i�� S r <br /> ��eu�r�h a� � <br /> � <br /> O <br /> a <br /> ACKNObVLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees lo hold and save harm- <br /> — /� less ihe City of Everett from any and all claims for damages, cosis, <br /> � / expenses, or causes ol action Ihal may arise because of installation <br /> ' �,.� . ` '•� _�3 and maintenance of the improvement or other right-o4way use hereto <br /> ��� applied for and further agrees to remove same upon notice Irom the <br /> • pproved tor Constructio Date City and to re I ce public property damaged thereby. <br /> / ' !`�-l� � -3 �^ <br /> INAL IVSPEC�ION Date O� ~� <br /> Approved as Constructed Sign re f Applicant Date <br /> evere[t PUBLIC WORKS DEPAFTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Street 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 �E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT M1tAY �E <br /> Phonr,: 259-8815 CANCELIED BYTHE CITY UPOIJ ANY STOPPAGE OF WOFK ON TNIS <br /> I PROJECT OVER 90 DAYS DUR�TION. _-. � <br /> r <br />