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- ����su'�=�.,�. .. <br /> Date �� �l'� I Fublic Work�PermM a �� �� <br /> Application For eia�oeoi.+ - � <br /> PUBLIC WORKS PERMIT °°°°°W°«.F°° <br /> Totelfee S <br /> lcee Appt Feo�a�d $ <br /> Ba4�ce0ue S ���p <br /> Print or Type Only <br /> fh�`s .Tk.�i�Cf�S %yc���v .�i� S�v. .5�4.. q �/�C� ��� -o� � <br /> O�iner Mailing Address Ciry Zip Pbone <br /> �Y'D B�J/L/�ltS l�/C, /�/(o3G� �-�S,IU, �. q�/��( 25�E -06 k(o -��+ <br /> Appiicant Malling Address City Zip Phone m <br /> Describe Proposed Work l�U�f � /¢ ��TA�/`�`�P �r/� /?.9G�- /�f �X /� � <br /> � � <br />, �• � <br /> y Im <br /> y � � m� I <br /> Project Adtlress(it known) d'�/S � v - � � Z I <br /> Attach low(4)copies ol plans for proposed work- Draw to scale and note the lollowing as applicable: � i+=i � , <br /> • PropeAy Lines • Centerline of street � q Z � <br /> • Outline and dimensions of all enisting and • Indicate North n � <br /> proposed struclures on fhe lol • Show any proposetl grading changes r x , <br /> • Existing and proposed u�ilities • Show measurements � 'j N <br /> < <br /> � <br /> DO NOT WflITE BELOW THIS LINE O Ay <br /> PERMI7 CONDITIONS O = m <br /> 1. All calls lor inspection shall 6e made 24 hrs, in advance- phone 259-88�5. � m y <br /> l 2. All work shall be pertormed in accordance with this permit and current City o1 Everett Design and Cons:ruction p <br /> Standards and Specifications. o r <br />` 3. Call Location Underground Service 48 hrs. belore you d�g.TOLL FREE NUMBER 1•800•424•5555. � 3 N <br />� m <br /> z � <br /> O � r <br /> A <br /> �--1 <br /> � <br /> n <br /> z <br /> � � <br /> � <br /> O � <br /> z <br /> 0 <br /> a � <br /> � <br /> m <br /> F <br /> � ACKNOWLEDGEME4T OF CONDITIONS <br /> The undersig�ed owner/applicanl hereby agrees to hold and save harm- ' <br /> less the City o( Everett from eny and all claims lor damages, costs, <br /> /� expenses, or causes ol action ihat may arise because ol installalion <br /> r and maintenance of lhe improvement or olher right-ol-way use hereto <br /> ' .�'�vb� � �-7/k, <br /> applied for and luriher agrees to remove same upon notice irom the <br /> Approved lor�istruction Date Ci�y and to repiace public property damaged thereby. <br /> �����;r/��._ 5% // �� �,� �t �f--�j� .�--v �/�.� /R`G <br /> FINACENSPECTION Date C� L'i'L � <br /> Approved as Constructetl Signature oi Applicant �T � <br /> everett PUBLIC WORKS DEPARiMENT WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Slreet 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIG[NiLY PURSUED 10 COMPLETION.THIS PERMIT MAV BE <br /> Phone: 259-8815 CANCELLED BY THE CIN UPON ANV STOPPAGE OF WORK ON THIS <br /> PROJEGT OVER 90 DAYS DURATION. <br /> � <br />