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-r <br /> 1 <br /> � <br /> Date <br /> AppliCation For P�b�'<Worke Permil• <br /> P���.�^ � eiap Deot e <br /> �• ORKS PitRMIT <br /> i � Puolic Worte Fee '� <br /> lotel Fee S��_ <br /> Print or Type Only LeeeApolfcePalE S ' <br /> Belance Due S (L' <br /> '7� W N+ �)QV[N lZ I�G l�1✓UQ � , <br /> Owner Mailing Atldress �Q� �i�/V��e �G2U� 7 ��q /� <br /> y Z�p � 7 7�� <br /> S Phone <br /> x ��r'e (31d�•s / . � (.' " <br /> Appllcant �c'�`� n � (iu�re 2�, , . <br /> Mailing Address ���Y �j : � <br /> Z�p Phone <br /> Describe Proposed Work ��'�5 vu pr,� � II <br /> . I'�+ ty C(2 <br /> S_f�.�cv ���[c / l Qv �v <br /> �-i— ----7--- —� <br /> Project Address(if known) � G � <br /> Attach lour(q)copies of plans lor proposed work• Draw to scale and note the lollowing as applicable: � <br /> • P�operry Lines <br /> • Outline and dimensions o�all exi:ting and � Centerline ol streef � <br /> proposed structures on the lot • Indicate North � <br /> • Eaisting and proposed utilities � Show any proposed grading changes <br /> • Show measurements <br /> DO NOT WRITE BELOW THIS LINE m <br /> PERA7(T CONDITIONS O <br /> 7. Ail ca�ls for inspection shall be made 21 hrs. in advance- phone 25g-gg�5 <br /> 2. All work shall be per(ormed in acwrdance with this permit dnd current City ol Everett Design and Construction <br /> Standards and Specifications. � <br /> 3. Call Location Underground Service 48 hrs bepre you dig.T'LL FREE N�Ep��424•555 . � <br /> T � "-�,� �J,���-�v-e. � `�/�.y-�.S � � z 7 83 <br /> / � �� <br /> 0 <br /> � <br /> � <br /> . 0 <br /> a <br /> ____ ACKNOWLEDG[MENT O�CONDITIONS <br /> / r The undersigned owner/applicant hereby agrees lo hold and save harm• <br /> less the City ot Everett Irom any and all claims for damages, co,^,ts, <br /> � _ /—' expenses, or causes of aclion that may arice because of instailation <br /> � �' � 1 and mainlenance of the improvemenl or other right-of-way use he�eto r <br /> Approvetl lor Constructiun Date aPp�1e or and her ag�ees to r move same upon nolice Irom the <br /> �-� � Cit n tn�epl ce p lic propert amaped thereby. <br /> �INA'L'TrySPECTION ���G � ���� � — <br /> 4pproved as Constructed Date � " � � q 4�n3 <br /> ' Siqnature ot ' � � �13 <br /> p�icant Dete <br /> everett PUBLIC WORKS DEPARTMENT WORK AUThORIZED BY THIS PERMIT MUS7 BE SfAqTED WI7HIi: <br /> 1 Q 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND 7HEREAFTER IS TO <br /> Everett,W'q 98201 BE DILIGENTLY PURSUED TO CGMPLETION. THIS PERMIT MAY BE �' <br /> `� '� Phone: 259-8815 CANCELLED BY TI IE CITY UPON AhY S70PpqGE OF WORK ON THIS <br /> PROJECT OVER 90 DqYS DURATION. <br />� <br /> � � <br />