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Date�,�.11(J-� 1 Puoucwo.��ae� i• � � <br /> Pinp�eD� � <br /> Application For <br /> PUBLIC WORKS PERMIT Pubi2Wor��ie� - � <br /> Totel Fee s-�� <br /> lau�oo� Fae P�iO S_-J/J��g— <br /> B�bnce Due � I <br /> Print or Type Only � <br /> /'/�/2Gf//�i r �i4/.'7'i5lE/�,�1 � <br /> Ownar Maihng Address ^ City Zip Phone ' <br /> ��r CiIY �p Phone <br /> Applieant Mading Address . <br /> Deee�ibePioOosedWork _ <br /> - W <br /> I`il.3O— L[/. Cf>S�/�/O •�'Tm�.r/i 1 � <br /> Project Addrees(11 knownl � _ � , �,;�5/NU Fd�/f.9k'� <br /> Altech lour�a)copies ol Plana 1or proposed work- Drew lo ecale a ote the Iollowing as applicable: � <br /> • Property Linee • Centerline ol atreel � <br /> • Oulline and dimenefona ol all exieling and • Indicete North <br /> propoeetl struclures on the lot • Show eny proposed pradinB chenges <br /> � Exfaling end proponed utllitiea • Show meeaurements M <br /> W <br /> p T WRITE BELOW THIS LINE O <br /> PERMITCONDITIQNS � <br /> 1.All calle for inepectlon ehell be m 4 hra.in edvence•phone 259•8810. <br /> 2.All work nhell be peAormed In ence with Ihla permit antl current City ol Everett Dealgn and Conatructlon <br /> Stenderds and Specllicallon � � <br /> 3.Cell locetlon Undergroun Ice 48 hra.belore you dig.TOLL FREE NUMBER 1•800�424•5555. <br /> _ ,� �� �r��s �a,�� �=��-� 9 �, � o <br /> � //- z� '� 9 <br /> H <br /> e N <br /> e o <br /> � a <br /> �� � <br /> . 1 . � <br /> ' � ' '� I NS <br /> ACKNOWLEDGEMENT OF CONDIT O <br /> �nderelgned owner/ePPlicanl herebY e9rees to hnld and eeve harm� <br /> less the City ol Everetl from eny and all clafrtis lor damagee. cosla. <br /> � expenses, or causes ol action Ihat mey arise because ol Instellation <br /> � end mainlenence ol Ihe Improvemenl or other righl-of•wey use herelo <br /> applied lor end lurther aBrees lo remove same upon notice Irom Ihe <br /> ved lor str on �e� City and to replace public Property damaged thereby. <br /> ' �-i2 - � �. <br /> FINAL INSPECiION Dale -� Dete <br /> �Approved es Construcled Signalure ol plicanl <br /> WORK A'JTNORIZED BY THIS PF.RMIT MUST 0E STARTED WITHIN <br /> � everett PUBLIC WORKS DEPAR7MEN7 I80 DP IS OF DA7E PERNIT IS ISSUED AND THEREAFTER IS Tf <br /> � � 3200 Ceder Siraet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY � <br /> E•�e�elt,WA 98201 CANCELLED BV THE CITV UPON ANV STOPPAGE OF WORK ON T <br /> � Phone:259-8^.10 PROJECT OVER 90 DAV:� DURATION. <br /> , � <br />