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Date��� PUEbc Wo�ke Peemll• "�� � �� <br /> eioc o�ot.. y �o <br /> Application For <br /> PUBLIC WORKS PERMIT P°°T�a�Faa`°° s <br /> Leaa auv�Fee Peie s <br /> Baia�ce�ue s ZG.Op <br /> Print or Type Only ��f0/ <br /> �Q� �iw � Iruw. .Mer /li2 Ce��Y �vere �' 98Zo / ZSz -E/6o <br /> � Zip Phone <br /> Owner Medmg Address ���Y <br /> ORTN SouND 6u ��D�Rs 91o�'SMok.yP� B/wo/ylpcysv '�i� $L�o Gs.�-2S �2 <br /> MaJin Addrese Gty ZiP Phone <br /> Applicant g <br /> z <br /> 0 <br /> ��D G�9�fA."e� Bul�-9 A/ti4/ C'� ��T D�fC /c .�. <br /> Deacribe PropOseQ Work ,T� D•w N � � c� <br /> m <br /> «. .. <br /> W �' �' <br /> � � <br /> p N S <br /> G' �6 LYtrf � � m <br /> Prolecl Address(il known) �� �2 O c o <br /> — m� <br /> Attach four(4)copies of plans for proposed work-Draw to scale and note the following as applicable: o m <br /> • Property Lines • Centerline of street <br /> • Outllne and dimensions ol all ezisting and • Indicale North = � <br /> proposed shuctwee on the lot • Show any proposed grading changes m � <br /> � ExistinB and proposed utilities • Show measurements M Q = <br /> DO NOT WfiITE BELOW THIS LINE O r" _ <br /> < y <br /> PERMITCONDITIONS � � <br /> 1. Atl cells for inspectlon shall be made 24 hrs. in advance- phone 259•881 5. o s <br /> T <br /> 2. All work shall be performed in accordance with ihis permi� and curreot City of Everell Design and Cunstruction �m <br /> Standards and Specificetions. � x <br /> 3. Call Location Underground Servlce d8 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. m.., <br /> N <br /> v <br /> O �m <br /> m� I <br /> z � <br /> � —�r <br /> • m <br /> A <br /> � _ <br /> O Z <br /> --I <br /> S <br /> � N <br /> Z <br /> O <br /> -�i <br /> n � <br /> m <br /> AGKNOWLEDGEMENT OF CONDI110NS <br /> The undersigned owner/applicant hereby agrees to hold aod save harm- <br /> less the City ol Everett from any and all claims lor damages, wsts, <br /> c'/�"" "' exPenses, or causes ol action that maY arise because ol installation ' <br /> /n /l n and maintenance ot ihe improvemenl or other righl-ot�way use hereto <br /> > !�dZ>jJ7 �/U/o� epPlied tor and further agrees to remove same upon notice Irom the <br /> Approved lor Conslruction �e�e City and to replace ubli erty damaged ihereby. <br /> `' �/ ' / s-�s�. 9 i ' <br /> AL INSPECTION Date Date <br />, Approved as Conslrucled Signa _ ol A cant <br /> WOR AU RIZED 8Y TH�S PERMIT MUST 8E STAfiTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO � <br /> I'� � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE I <br /> Everett,WA 98201 CANCELLED BY THE Clri UPON ANV STOPPAGE OF WOfiK ON THIS <br /> Phone: 259�8815 PROJECT OVER 90 DAYS DURATION. <br /> � <br /> I I <br />` <br />