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il <br /> i p8��� Pub�lc Work�Per <br /> Application For <br /> BiCp.DepL• � <br /> PUBLIC WORKS PERMIT P�����workaFee <br /> Totei Fee 5 <br /> lus�Apo�Fee PaiE � <br /> Print or Type Only BaienceDua s <br />' �����I�� �� �� _ r��o� �3 ��t— a.ss- v,�.�-y <br /> Owner Mailing Address City Zip Phone <br />� �i �'e Cv�;7T /�D �o� /5� ��`7`A.z�u,o �J� 75�3 - /„� c�G� Z <br />� Applicant Mailing Address City � Zip Phone � <br /> n n n / ['� <br /> � �a-��f' . cx.Zcnh 1� ���c�' 4��.�, Cc.�ti � � <br /> Describe Proposed Work G �_ � <br />� --� � <br />� «. —� <br /> �n s <br /> i � m <br /> 0 <br /> co i <br /> � ri o <br />�' P�olect Add�ess(if F.nown) 0 3 � <br /> Attach four(4)copiec of plans for proposed work- Draw to sc e and note tne lollowing as applicable: � ,� _ <br /> • Property Lines • Centerline ot street � x � <br />' • Outline and dimensions ol all existing and • Indicate North m �+ <br /> proposed slructures on the lot • Show any proposed grading chenges � _ <br /> • Existing and propo,ed utilflies • Show measurements � � _ <br /> DO NOT WAITE BELOW THIS LINE s T <br /> PERMIT CONDITIONS O � 3 , <br /> 1. All calls br inspeclion shall be mede 24 hrs. in 2dvance-phone 259•881 5. � .--� m , <br />� 2. All work shall be pe�lormed in accordance with this permit and current City of Everetl Design and Consiruction = <br /> m � <br />, Standards and Specilications. v+ <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•S00•424-5555. o r <br />, � mN I <br />� / /-� z c� <br /> /�>� �l/��'/C �'r�O,f.�,S !"C�/r'/T �a <br /> � � A <br />� /Cl`�lir,��-o � <br /> _ <br /> b <br /> E � �� � �' � -�-1 <br /> �_ �- .�� O ._-� <br /> V N <br />� a Z , <br /> a <br /> � <br /> � <br /> r <br /> m <br />� ACKNOWLEDGEMENT OF CONDITIONS � <br />� 7he undersic�ned owner/applicant hereby a9rees to hold and save harm� <br /> less the Cily of Everett from any and all clalms for damages, cosls, ' <br /> eapenses. or causes oi action that may arise because of inslallation <br /> antl maintenance ol the improvement or other righl-of-way use hereto <br /> applied for and lurther agrees lo remove same upon notice from ihe <br /> Approved lor Consfruction Date Ciry and to replace public properry damaged thereby. <br /> I <br /> FINAL INSPECTION Date <br /> Approved as Construcled Signature ol Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED EY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarSireet 1B0 DAYS OF DAT[ PEflMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,VJA 98201 BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone:259•8815 CANCELLFD BY THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 UAYS DURATfON. <br /> � <br />