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Date r ' �%. "" . / ' _. <br /> � Pu01i'.:Po.pAc pr�mi�/ <br /> ( � � <br /> Appllcation For eiao�oem.. ���� ' � <br /> PUBLIC WORKS PERMIT PubTolelFee`°° s <br /> I.C69 ApO�F!B Pp�E $ <br /> Print or Type Only BalanceDue s <br /> ���1-(i. �, - �����' U-\f� ll� .')�: , � �ll�,.�� :-�-�i j � �l'��� G- � ,r�}��1� (T� `� �. 'l�i ,,--� '�-� �11�J <br /> Owner Mailing Addiess City 2ip Phone <br /> •� (� 1 ��12� <br /> Applicant Mailmg Address Cfty Zip Phone <br /> Descri6e P�oposed Work �.�)��f 1 I l`��1� �`�� � � <br /> � � W <br /> Proiect Address(il known) •�-����''� �__: . ��.� � � <br /> Attach four(4)copies ol plans for proposed work- Draw to scele and note the lollowing as applicable: � <br /> • Properry Lines • Cenlerlin�ol slreet � <br /> • Outline and dimensions ol all existing and • Indicate Nortb <br /> proposed st�ucW res on ihe bt • Show�ny proposed grading changes <br /> • Exiating and proposed util�ties • Show measurements � <br /> ' DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1. All calis I�r inspection shall be made 24 hrs. in edvance� phone 259•881 5. � <br /> 2. All work shall be perlormed in accordance with Ihis permit and current City ol Everetl Desi3n and Construction <br /> Standards and Specilir.alions. <br /> 3. Call Location Underground Service 4A hrs. belore you diy. 70LL FREE NUMBER 1•800�424•5555. � <br /> / vPL�� G.(/UIE��� �',E/c/J-��/ /V�T /�,��I�l�.!'•ir� �/��/�l � O <br /> ��/ � <br /> � <br /> O <br /> a <br /> ACKNOWLEL'GEP.1LN101=CONDITIONS <br /> The undersigned owner/apphcant hereby agrees to hold and save harm- <br /> less the City of Everett irom any antl all claims lor damages, costs, <br /> expenses, or causes ot action that may ari5e because ot installation <br /> and maintenance of the improvement or other ught�of-way use ncrelo <br /> applied tor and further agrees to remove same upon notice Irom the <br /> Approved lor Construction Date City and to replace public property dama�ed thereby. <br /> FINAL INSPECTION Date <br /> Approved as Consiructed Signatu�e of Applicant Date <br /> � everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST DE STARTED WITHIN <br /> � 3200 Cedar Sireet 180 DAYS OF DATE PERMIT IS ISSUED AND THER[AFTEf? IS TO <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLEiION, THIS PEHMIT MAY BE <br /> Phone: 259-6815 CANCELLE�6Y THE CITY UPON ANY STOPPAGE OF WORK OIJ 7HI5 <br /> PROJECT O.iER 90 DAYS DURATION. <br />