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� <br /> r Date � b� �j� <br /> Pu�iir'Nork�Permit r <br /> Application For eiao�oee�.• <br /> PIiBLI� WORKS F�ERMIT P����<WnrknFee <br /> :o�e�Fae s <br /> Lee�ApO�fee P��O S—�' <br /> Print or Type pnly e.�a�,eo�a S.�C�O �1 <br /> . �� , ,.'�qkl.� .�' '�"7t�7� <br /> ,�=.�T� 7,�7r�� ��S1`-�-� �S3 6'�x- <br /> Owne� Mailing Addres; � r,i�y Zip Phone <br /> Applicant Mailing Address Ciry 2ip Phone <br /> Describe P�opo;;ed Work � . � � � ����j N� <br /> ��d�� ���,��_�c �.s' �� "�J -- — <br /> � <br /> ��_ <br /> _��>✓ �!� —'- �'j:7 r - . � <br /> .��J �/� 7 L— ; 0 <br /> Project Addreas(il known)�� ��� �- � <br /> Altach four(4)copies of plans lor proposed work• Draw to scale and note the lollowing as applicable: <br /> • Property Lines � <br /> • Centerline of street I_ <br /> � Outline and Aimensions of all existing and • Ir.dica�e Norih <br /> proposeJ structures on the lot • Show an � <br /> P Existing and proposed utilities Y Proposed grading chan�e� <br /> • ShoH measuremenf; � <br /> DO NOT WRI'F B[LOW 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 perlormed in accordance v.•ith thi;pernit and current City ol Everett Design and Construclion � <br /> Standards and Specifications. <br /> 3. Call Location linderground Sorvice 48 hrs. betoin you dig.TUi.L FREE NUMBER 1-800-424•5555. <br /> � %0 6'E L'Gy5T:c�G�G.TcG.l, A� PE.c� PC.d ic/S � <br /> .O.ct i E:O .d�C.{/� �Q/�i�OY�� �il/ //•8- c�yc � <br /> _ � <br /> � �� o <br /> ��' � �' � � a <br /> � - <br /> � <br /> ACKNOWLEDGEMENT OF CUNGITIONS <br /> — ___ The undersigr�ed owneryapplicant hereby agrees to hold and sae?harm- <br /> less the City ol Everetl Irom any antl all claims tor damages, costs, j <br /> � / expenses, or causes of action that may arise because of installation � <br /> �„,/'/ �� ,�o/ai/ and maintenance ot Uie improvement or other righl�obway use hereto � <br /> ^ ��– `"" ' �� `�—� a lied for and �wther a rees to remove saine upon notice from the �� <br /> Approved lor Const uclion a�e Cpy and lo rep c publio property damaged thereby. <br /> , <br /> , FINAL INSPECTION Oate <br /> i • c'J +• <br /> Appro•.ed as Constructed Si nature ol App icant ate � <br /> everelt PUBLIC WORKS DEPARiMENT WORK AUTHOFIZED BY THIS PERMIT MUST BE STARTED WITHIN ' <br /> � 3200CedarSireet 190 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFTER IS TO �, <br /> Everelt,WA g8207 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8815 CANCELLED 8Y THE CITY UPO4 ANY STOPPAGE OF WOi7K ON THIS � <br /> PROJECT OVFR 90 DAYS DURATION. <br /> �, J <br /> J <br />