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� - � - - <br /> Date� V� J PoObc n'orls Permn+ BO�I <br /> Application Fot Biap Dept• <br /> PUBLIC WORK� PERMIT PubbcWOM1aFee <br /> TMaI Fee s <br /> Lese Appl.iee Pak s �/ <br /> 0e4nce Due S d 0 00 <br /> Print or Type Only <br /> �.���'� Irl� I �ISi- �f- #�lB �C�'�� �'T1�1 7�A/.�n77_, <br /> Owner MaiHng Adtlress City LP Phone <br /> �4/� <br /> �' qpp�{�e�� Mailing Atldress City Zip Phone <br /> Describe Propased Work �fJX�r!<--� J FK (v �� {^1 �'" <br /> - W <br /> Project AdOress(il known) � <br /> Attath lour(4)coDies o1 plans fOr proposed wOrk• Draw t0 SCale and note the lollowing as aUpliCable: � <br /> • PropeAy Lines • CenleNine ol sireet � <br />' • Oufline and dimensions ol all existing and • Indiwte North <br /> proposed s�ructwes ontheiot • Show anyproposed gradmg changes <br /> • Ezisting and proposed ulilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.AII calls for inspection ehall be made 24 hrs.in advance•phone 259•8870. � <br /> 2.All work shall be peAormed in accordence with this permit end current City ot Everatl Design and Conslruction <br /> Standards end Specificalions. <br /> 3.Call Locetion Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> �'oNv�-� s.a� .S'Ei.�,�,e F�o�n Y" ��9rn�r�,� O <br /> To �9 � "���-E•�z o,d i�.ei✓.orE � i�,Pa�E.er/y, � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMcIJT Of CONDITIONS <br /> The undersigned owner/applicanl hereby agrees to hold and 5ave harm- <br /> less the City ol Everell from any and all claime lor damages. costs, <br /> — expenses, or causes of aclion that may arise because ol installation <br /> , �' and maintenance of the improvement or other right-ot•way use hereto <br /> < - applied for and furiher agrees to rr,move same upon notice from the <br /> Apdr ed for Con o ate Ciry and to replace public properry damaged thereby. <br /> / p <br /> O^ �� <br /> FINAL INS CTION Date �.+� �'� - ���4 �I^O�� <br /> Approved as Constructed Signature ol Applicant Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPAFTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cetler S�reet BE DILIGENTLY PURSUED TO COIv1PLETION.THIS PERMIT MhY 8E <br /> Everett,WA 98201 CANCELLED 0v 7HE CITY UPON ANY STOPP.4GE OF WORK ON THIS <br /> Phone�,259�BEt0 PROJECT OVEA 90 DAYS DURATION. <br />