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/�����O� PubLc Works Pe•mil• <br /> Date 1!l[h (� <br /> eiaa oeo�.• <br /> Application Fo: <br /> PUBLIC WORKS PERMIT Pu01¢WorxeFee <br /> Tolsl Fee s <br /> Lene ApO�Fee PerC $ <br /> BelentaDua $ <br /> Print or Type Only <br /> �1�l�ai�' Jl'�11�.1��1r ►'�2lY��llJl�a/ �S� `-��� <br /> Owner Mai4ng Addres City Zip ��� Phone <br /> o�(/ 1�� � � )Jl - <br /> �' 100�-� <br /> Appl�an� MaJmg ddress Cily Zip Phone <br /> n r.l�,=n�n J <br /> Describe Proposed Work �-� <br /> _ W <br /> Project Address(if known) ��`� � <br /> Attach four(4)copies ol Flans for proposed work- Draw to scale and note the foilowing as applicable: � <br /> • Property Lines • Cent?rline of Street � <br /> • Outline and dimensions o1 all ezisting and • Indicate Norih <br /> proposed stiuctures on the lot • Shcw any proposed grading changes <br /> • Ezisting and proposed utililies • Show measurements � <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 accord3nce with this permit and current Cily ot Everetl Design and Consiruction <br /> Standards and Specitications. <br /> 3. Call Location Underground`.iervics 4D hrs. before you dig.TOLL FREE NUMBER 7-800•424•5555. � <br /> � , � . ,. . :' � . �. ,�- - � �, - . .. . � O <br /> 'f�r �-S /�- `� /' � ' � .� /-, �-z5c� -�'fJ � <br /> i <br /> ��-�'��f, �- <br /> � V� <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF COIJDITIONS <br /> The undersigned owneVapplicant hereby agrees to hold and save harm� <br /> less the City of Everett irom any and all claims for damages, costs, <br /> expenses, or causes of action that may arise because of instaltation <br /> and maintenance ot the improvemeni or olher righl-of�way use hereto <br /> applied tor and further agrees to remove same upon notice irom the <br /> Approved for Construction Date City and to replace public property damaged thereby. <br /> FlNAL INSPEC710N Date <br /> Approvr.d as Constructed Signature of Applicant Date <br /> PUBLIC WORKS DEPARTMENT WORK AUTHORI'.ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett 180 DAYS OF D�.TE PERNIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE L'LIGENTLY P:JRSUED TO COMPIETION.THIS PERMIT MAY BE <br /> Everett,WA 96201 CANCELLED BY 7H::CITY UPON ANV STOPPAGE OF WORK ON THIS <br /> Phone: 259-dB75 PROJEGT OVER PO DRYS DURATION. <br />