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Applicetbn Fa � <br /> ���� f�UBGC WORKS PERMIT De'��,s�-� _ <br /> PUBLIC WJRKS DEPARTMENT Public Nbrks PemNl 1 �� O�� <br /> 3200 Cedar St�eet <br /> Everetl,WA 96201 259-6810 � P 8 � gui�ding Pertnit N 61397 <br /> T'PE OR PRINT ONLY TO PO STI N G public Works Fee S�A_ <br /> GARY JELLISON PO BOX G241 LYNNWOOD WA 9$036 425-750-0615 <br /> Owner Mailing Address City Zip Phone <br /> Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work NEW HOUSE — BASIC 2022 � <br /> � <br /> � <br /> � <br /> PROJECT ADDRESS(if known) 5409 BROADWAY � <br /> Attach four(4)copies of ptans for pmposed work-Draw tu:;wle and note the lollowing il applicable: O <br /> •Property Lines 'Outline and dimensions oi all eaistin;�a�a propoaed structures on the lot •Existing and proposed utilitles <br /> 'Centedine of sireet •Indicaie North •Show ai;�proposed greding changes •Show r�ieaswemenis � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS: � <br /> 1. All calls for inspection shall be made 24 hours in advance- phone 259-8810. O <br /> 2.All work shall be performed in accordance with this permit and current City ot Everett Design and <br /> Construction Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 7-800-424-5555. � <br /> � R��nftoE, ruucdl'�diould U�• di�ch�i,�cd to root��uuoll�inliltratiou sy�tcm� de�:iRncd nud cou<irncl�, � <br /> ui accmdancr�ti7t6 city slsmdard�, if the soilF on ihc sitc. O . <br /> I)rivz«;ips :uid privFilc acceas roada should be designcd vid constrvcicd to prevent thc collection a <br /> nf storni watcr. <br /> � IrJillratieu systetus providrd ibr rooftop swd!or c6�ivewt�y ninofl�must be desiened tiid located to <br /> ,ivoid ueqative impactv to the new Iot� and to acljacent prope�ties, in pa�icular. T7ie potentia! <br /> ,idve�se elTects ou existing mid propo�ed buildiqqs ;u�d othcr slntctures n�ust be consider�d �nd <br /> n�oided. 1f inliltration ayet�:m: ca�uiol bc located to avoid potential adverse ef3ects, an alteni;de <br /> m:•Ihod of ston�t µ�iter disposal must bc providcd. <br /> �U (; iNi', to ;i��ure compli;uu�� �t�lh Iheir rccomtnend;dion�, mu�l a��proc� the propo��d <br /> r�id:n�:��. <br /> � WL EMENT OF CONDITION <br /> The undersigned owner app ican ere y agrees to io d and save hartnless <br /> � Z 9 the City ol Everett from any and aIl clalms for damages,costs,expenses,or <br /> Appro ed lor Cpnstmction Dato — causes ol action that may anse because ol installatlon and malntenance of <br /> the improvemenl or other ngh4of-way use hereto applied tor and lurther agrres <br /> ` to�move same upon notice from the City and to replace public pmperty <br /> �+�G �i—�O —�5' damaged thereby. <br /> Al INSPECTION Date <br /> Approved as Const/ucted <br /> Signatufe of ate <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE S7ARTED WITHIN 180 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFfER IS TO BE DILIGENTIV PURSUED TO <br /> COMPLEf10N.THIS PERMIT MAY BE CANCELLED BY THE CIN UPON AN\'STOPPAGE OF WORK ON THIS PROJECT 0\�ER 90 DAYS DUFiATION. <br />