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Date G�' � � I <br />Application For <br />PUBL:L VI/ORKS PERMIT <br />Print or Type Only <br />�`_'_Y �� � � <br />Owner <br />Apphcan; <br />Address <br />Mahny ACdress <br />.�� � <br />Describe Proposed Work `��. <br />Project Address Iif knownl 7Y"/-� '��'�n'g����� <br />, �c, <br />�� <br />Ctly" Zip <br />Zip <br />%�9 ' <br />� 'J <br />PubLe Wo�kf Parm�t • } _ <br />8��0 Deot n � _I ��'�_. <br />Pubhc Wo�ke F¢e <br />Tctnl Fee � <br />Le55Appl F¢ePaiO $ <br />�atance Duu $ '�� � _ <br />Atlach lour (4) copies ol plans for proposed work - Draw to scale and no'e the follov.�ing as applicable: <br />• Propr.rty Lines • Centerline ol sireet <br />• OulGne and dimensions of all existing and • �ndicate North <br />proposetl structures on Ihe lot • Show any proposed grading changes <br />• Ezisting and proposed utilities • Show measurements <br />///. __///_ <br />�,��"7l 5 3 <br />?hone <br />PERMITCONDiTIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259•8810. <br />2. All woik shall be pertormed in accordance wilh this permit and cu�rent City of Everett Oesign and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />7-. G/2A.O.s �✓E'CJ IJ.E'i!/.�2c/9� �AT TO <br />CGTT-B9��f" Tif�� !�P T� Cc?T fiS SNO<</,(/, <br />-%=XiSi�.t/r� GUT-d'7n/%C <br />�� <br />j <br />E'x�5ri.��c <br />i>a'i� fr,</�+i <br />C.:,�'Di' � <br />, � , / R'E4��i,�'ED <br />� �t/E«� D�c'r✓Fcdn�/ C-�.A�E. <br />W <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />h�!'tii���� Cr'oSs S£Ciioti! <br />� i NCbfT//� ACKNOWLEDGEMENT OF CONDITIONS <br />�con.e �r <br />The undersi�ned owner/applicant hereby agrees lo hold and save harm- <br />less the Clly ol Everett irom any and all claims for damc�es, costs, <br />expenses, or causes ol action ;hat n.ay arise because ot instal'���.on <br />� ��� and maintenance of lhe improvement or other righhol-way use hereto <br />- applied lor and lurther agrecs �o remove ,ame upon notice Irom the <br />�, , Date City and to replace public property damaged thereby. <br />FINhL TNSPECTION ' � L� <br />Approved as Consiructed <br />everelt PUBLIC WORY.S DEPARTMENT <br />� 3200 Cedar Slreet <br />Everett, WA 92201 <br />Phone: 259�8870 <br />� ���� � ', ��� � <br />Signature ol Applicant Date <br />WORK AUTHORIZED Ll1' THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PUFSUED TO COMPLETION. THIS PERMIT MAY 8E <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />a,.::�; <br />M �z �*'f <br />YE,.V,. <br />