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Date (°�� PubI1cW0�MSParml�. _,_ �/�(�� <br /> Bltlp.Dep1.+���J.2L1�_ <br /> Application For <br /> PUBLIC WORKS PERMIT Pu�lipWorAsfee — <br /> .e�a�Fae s—_ <br /> Lese AoO�Fae PaiC S <br /> �aience�ue S <br /> Print er Type Only <br /> L�PlQi� Sc�.� �C+��L�'/S �'C' ' (�f..1� l��/� C✓P/P�{ Q,PJ06 0��' —3�0�0 7 <br /> Owner Mailing Address City Zip Phone <br /> 1�br���. �,G,h'�„� iz94 �cer�9�znc as�`-3��,� <br /> Applicart ' MailingAddress City Zip Phonc <br /> Describe Proposed Work �P�(j�� (t1���l�i✓n M PA/ h i //j� Istf _ _ <br /> W <br /> Projecl Addre3s(if known) Z�O Z S rn��. � <br /> Aitach four(4)copies of plans for proposed work- Draw to scale and note the following as appliwble: � <br /> • Property Lines • Centerline of street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed struG.ures on the lot � Sbow any proposed gradin��changes <br /> • Existing and proposed utilities • Show meaaurements M <br /> W <br /> DO NOT WFITE BELOW THIS LINE O <br /> PERMIT CONDITICINS <br /> 1. All calic tor mspecNcn shall be made 24 rrs in advance• pho�ie 259•S81 5. � <br /> 2. All work.shall be pr��formed In accorclence with this perm;t aM �urrenl Ciry ol Everett Design and Construction <br /> Stand�rds and Spudlications. <br /> 3. CaIII.n:eGnnUndr.iground5ervicn�? '+�> b�'�r?youCinipU.FREENUMBERI-800-424-5555. � <br /> /(/D f U.��c:�C l�Jpi�E:C ,c�/>> >. O <br /> /�`� �, /��dti..i'<='ti <br /> Fo� jr.v;�_�:v.,� c����,�' G y-87 <br /> -=�.�:.L H <br /> N <br /> O <br /> a <br /> ACY.NOWLED.riEMENT OF CONDITIONS <br /> The urdersigned owner/appliwnt hereby agrees to hold and save iiarm• <br /> less tha City ol Everett Irom any and all claims br damages, costs, <br /> ezpens�s, or causes of action that may arise because ol installation <br /> and maintenance ol the improvPment or other right-of-way use hereto <br /> applied tor and lurther agrees i� remove same upon notice from the <br /> Approved for Construction Date City and to replace public property damaged thereby. <br /> FINAI. INSPECTION � Date <br /> Approved as Constructed SignaWre ol Applicant Date <br /> eeerett PUBLIC WORKS DEF.•.HTMENT WORK AU?HORIZED EY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 CedarSlrcet 180 DAY'S OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE D�LIGENTLY PURSUE� TO COMPIETtON.THIS PERMIT MAY BE <br /> Phone: 259�8815 CA�CcLLED BY THE CI7Y Ur'ON ANY STOPPAGE OF WORK ON THIS <br /> P(iCU�CT OVER 90 DAYS DURATION. <br />