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86 —�ss� <br /> late�{O y� auoi�c•xc�wa ae�mn= _ <br /> e�ec oeci . Sf���7�5� <br /> App��cation For <br /> PUBLIC WORKS PERMIT vuoucWonuFee s _ <br /> Totnl Fee <br /> ltc5 Appl fe!Pa'4 S �� <br /> Bela�ce Doe S <br /> Print or Type Only <br /> -ra� k H P4 T� 3 33o m�D��L��Q-�� vn�nr/r�i,� Qd arq/ <br /> Owner <br /> Mailing AdCressJ C ty Zip Phone <br /> l-. ! /� . /_ . / _ _ �:f � /�nX���9 � ��. i �G��10 r�v�6 �J�b�O 7 <br /> Applican� <br /> Madina Address City Zip Phone <br /> i •/ e�- /-Q M�2tL�/A� �!� rn ia �o�l � <br /> Describe Proposed Work J <br /> �r��---T <br />� W <br /> Project Address(il known) � � <br /> � <br /> Attach lour(4)copies ol plans for proposed work• Draw lo scaie an note the lollowing as aAPlicable: � <br /> • PropertY Lines • Centerline of sireet <br /> • Outline and dimensions of all ezisting and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW 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 with ihis permil and current City ol Everett Design and Conslruction <br /> Standards and Specilications. � <br /> 3. Call Location Underground Service 4B hrs.�elore you dig.TOLL FREE NUMBER 1•800•424•5555. <br /> C�i'T,!'/f �i�s'/� Tv 8E Tir/Si,9GG E� O <br /> /.;v ���1(/i.QE.� 8 P!/BG/C GJO�rC-S � <br /> ��inii 6 -3S�SEE f7r,9C.yF� V� <br /> -�/„�,j �P�Y✓'��7 (�/u S o <br /> J �"' /' y�j <br /> _ �ga����� n F�., G. (�. w/,�.,� J�% -��/ �/' 0- <br /> Gv�cY CO.�HPvt`r��/v C� �C �S�N' (DNe �('OC{G ✓I�O/�'1 , <br /> t, �3. , h � l(P U ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less the City of Everel� Irom any and all claims tor damages. costs, <br /> expenses, or causes of aclion ihat may arise because ot i�stallation <br /> ' i � and maintenance ol �he improvemeM or other righPol-way use herelo <br /> '� _ /� �� � appf �or and further agrees lo remove same upon notice irom ihe <br /> A r d lor C ~tructi �f2�k-GL'r� Date Cil a d to rePlace Public ProPerty dama9ed lhereby. <br /> % <br /> 2 -�2' �_ /1 d fL <br /> FI L INSPECTION �a�e Date <br /> Approved as Constructed 5 nature ot Ap Icant <br /> OfiK AUTHORIZED THIS PERMIT MUST �E STARTED WITHIN <br /> e��erett PUBLIC WORKS DEPARTMENT �g0 DAYS OF DAT PERMIT �S ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY 8[ <br /> Everett.WA 98207 GANCELLED BY THE C�TY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8815 PROJECT OVER 90 DAYS DURATION. <br />