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4" <br /> Date�Q� � � I � )g <br /> WOLC Wor�{P.rmq• <br /> AppliWitO��ror Bap.Dect+ <br /> PUBLIC WORKS PERMIT .� P+oecWor.eFee - <br /> /�� -1 Totel Fee s <br /> (,�'t � Lea�Apo4 Fee Fera S� <br /> ! <br /> Print or Type ONy (7 6a`anceDue s <br /> � �'�.. LC.�1'Z]��' P,�1 I al$ � -�v� �����1y�L� � <br /> h Owner MaiNng Atltlress �ty 2ip Phone <br /> �c�l�rr1� aF� �i �,� ��� <br /> Applicant Maihng Address Cify Zip pc�ne <br /> Describe Proposed WorY. ���J �o�� u/\11 1 t. <br /> � W <br /> f Project Address(il known) -3�/O— COG/.3 f�I/F' � <br /> � Attach four(41 copies ol plans for proDosed work- Draw to scale and nute the foilowing as apalicable: � <br /> • Property Lines • Centerline 01 Streei � <br /> • Outline and tlimensions ol all existing anA • IndiCate North <br /> proposed shnCvras on the lot • Show any proposed greding changes <br /> • Er,lshr.g an0 prnposed u�ilities • Show measuremenis � <br /> DO NOT WRITE BEIOW THIS LINE <br /> PERMIT CONDITIONS <br /> � � <br /> t.All calls tor inapection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shell be pertormed in accordance with this permit and cunenl City ot Everett Design and Construction <br /> Standerda end Speci(icatione. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FHEE NUMBER 1-800•424•5555. � <br /> �. P.�,� ���,u„�� �,�,5 �-�� .�-�-g9 � <br /> H <br /> N <br /> O <br /> a <br /> A�nNOWLEOG'":AENT OF CONDITIONS <br /> The undersigned owner'c,pticant h�:eby agrees to hold and save harm- <br /> less the City oi Everett Irom any and all c�aims lor dameges, cosis, <br /> � ezpenses, or causes oi action lhal may arise because ol instailatien <br /> 6 and mainfenance of the improvement or other right•ohway use hereto <br /> App ed f o� tr applie r an4 f rt er agrees to remove saihe upon notice from the <br /> / Date City a d t cepla blic perty maged thereby. <br /> Gv � /--- . <br /> FINPI I,NSPECTION Date .—•�� 3 9 $� <br /> ADProved as Construcled gna re ol App cant Date <br /> everett PUBLIC WORKS DEPARTMENT � WORK UTHORI ED BY THI3 PEf1 IT MUST BE STARTED�WITHIN <br /> � 3200CederStreet . 180 DAYS OF D TE PERMIT IS 'SSUED AND THEREAFTER IS TO <br /> Evaretl,WAgB201 BE DILIGENTLY PURSUED T7 CUMPLE710N. THIS PERMIT MAY BG <br /> Phone:259-8870 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 9C ^4VS OURATION. <br />