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i . . . '. , .t�(•... ..-Y . �;� - --n .._n .:__z,.:�-�-.. �.. ..1 <br /> _����i f..`� .-� <br /> �ate ' PuOLc Work�Permit• <br /> Application For e�eo oeo��• � (�p������_. <br /> PUBUC WORKS PERMIT PuolicWo�bFee <br /> imeiF.e S <br /> Lesn Fpol iee PnJ S _ <br /> Print or Type Only BalanceDur s <br /> /�' � ,A 1/J��DM�1'!/1w o7Ci o�a �/�s. GG.�'.P /-„'�-�l !/ �'oZQ� '�S�-/'�.�� <br /> Owner MaiNng Atldress / City Zip Phone <br /> /� �) ���,,y� � y�� <br /> �� �t �P Y�i,rAC./� �f4l�J ,✓J ' -fi�J ii/L��D! /"G�CY 7.S� �Q ���/�f� <br /> Applican� Mailing Address City Zip Phone <br /> Describe Proposed Work �-1A . L1��� >A(�'�,d �A ' ��-����� /�a��� <br /> � �� <br /> Pmjed Address�if Imown� � � <br /> Attach four(4) copins of plans for proposed work• Draw to scale and note the lollowing as applicable: � <br /> • Property Lines • Centedine ot sireet � <br /> • Outline and dimensions of all existing and • Indicate Norih <br /> proposed sVUClures on ihe bt • Show any proposed grading changes <br /> • Existing and proposed utilitles • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> � 1. All calls lor inspection shall be matle 24 hrs. in advance• phone 259-8$�5. � <br /> 2. All work shall be performed in accordance wi�h this permit antl current City of Evere�t Design and Consiruction <br /> Standards end Specilications. <br /> 3. Call Location Underground Service 48 lirs.belore you tlig.TOLL FREE NUMBER 1•800•424•5555. � <br /> �UD �U��iG /:.�i�,�'�S �E�2�»iT � Jc�F9l/i.PF� O <br /> �- . -C�`✓/ �/�f�/96 � <br /> � <br /> O . <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less the City ot Everetl Irom any and all claims for damages, costs. <br /> expenses. or causes ol action that may arise because ol installation <br /> and mamtenance of ihe improvement or other righPoFway use hereto <br /> Approved lor Construction appiied for and IuAher agrees to rernove same upon notice from the <br /> �'�e Ciry and�o replace public property damaged thereby. <br /> FINAL INSPECTION Dale <br /> Approved as Consiructed Signature of Applicant Dale <br /> WORK AUTHORIZED BY THIS PERMIT MI 5T BE STARTED WI7HIN � <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUEC' AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLE�f10N. THIS PFRMIT MAY 8E <br /> Everett, WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8815 pROJECT OVER 90 DAYS DUR4TION. <br />