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Date��_ � ; ,�. ,_. <br /> �� ��;!i �_������,�-.���,�,: — <br /> � ' > � <br /> Applicatio�For o�nc oeo� •.-7'-,;J <br /> PUBLIC WORKS PERIIAIT P°°��W°���°°° <br /> ,o,.��� s <br /> less�ou�Fee�e�a 5 <br /> Print or Type Only e��.,���o�� a <br /> ( �'Acir���'C�� �''/� 1��� ��c-> � <br /> Owner ,. allingAtltlress Gty 7��p Phone <br /> � ��__I c�7�1 ){2"�'' ���� ����� _— <br /> Applicant y`� Mailing Address City 2ip Phone <br /> Describe ProPosed Work _ �jS�� ! �/��'�^�r J� �-�u ti� r � �"� ' U^�I� <br /> Proiect Adtlress�N known) �• ���� � � � <br /> Attach four(41 copies of plans tor proposed work- Draw to scale� note the lo�lowing as appficaUic: � <br /> • Properry Lines • Centerline ol street � <br /> • Outline antl dimensions ot all eKisting and i Indicate Nor�h <br /> p�oposed siructures on the�ot • Show any proposed gratlmg changes <br /> • Exis�ing and proposed iitililies • Show measuremenls � <br /> DO NOT WRI1�E BELOW THIS LINE O <br /> P[RMIT CONDITIONS <br /> 1.A�I calls for inspection shall be made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shell be performed in accordance with this permit and current City ot Evereft Design and Conslructlon <br /> StandarAs and Specitications. <br /> 3.Call Location Untlerground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> 1 �t,� v'���( ; l ����L� � <br /> n / <br /> !�n���f� � <br /> ��i- �� `�F' � <br /> O <br /> a <br /> ACKNOWL[DGEMENT OF CONDITIONS <br /> The unders�9neA owner/applicant hereby agrees to hold and saoe harm- <br /> Icss ihe City ol Everelt Irom any and all claims lor damages, costs, <br /> eapenses, or wuses ol action ihat may arise because ol installation <br /> and mainlenance ol the impro�ament or olher ngM-obway use hereto <br /> applied lor and lurther ayrees to remove same upon not�cr Iroro the <br /> Approved for Construction Date Cily and to replaco pubhc pioperty damageA therebv. <br /> FINAL INSPECTION Date <br /> APproved as Constructed 5�9nalure of Annhcant �ato <br /> everetl PUBLIC WORKSDEPARTMENT WORK AUTHORIZGD BY THIS PERA1IT IdUST BE STA9TED WITHIN <br /> � 3200CedarSlreet 180 DA1'S OF OATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> EveretL WA�B201 BE DILIGENTLV PURSUED TO COMPLETION. THIS PLFMIT tdAY BE <br /> Phone�.25&8810 CANC[LL[D ElY TH[ CITY UFON/�NY STOPP�G[ OF WCRK ON TFIIS <br /> Pi70JECT OVER PO DAYS DURATION. <br />