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_ � <br /> r� � <br /> Date/�� /�v(p � ._ <br /> (L�LC�,) PuEGc Works PermH s <br /> � � Biap.Oeot r <br /> Application Por <br /> PUBLIC WdRKS PERMIT P�°;;WFeFee S �,� <br /> lecs Apo�Fee Pe10 $ ��_ <br /> Print or Type nnly BalanceDue S Z-S�f �� <br /> G5�7S8� <br /> `��-�'[7th1 .��'„�f ./�S ShG� <br /> Owner ��— Mailing Address City Zip Pho�ie <br /> �r-+-A-►h p r c�ti� � rz �� �I ,�- 2 5'�( � ► � <,. <br />� Appticart Mailing Address Ciry Lp Phone <br /> Descdbe ProPosed Work �( )��� C_ �.�%d'fz,�� I !11 f-���/� IJ'�'C — <br />, � <br /> Prolect Address Qf known) �� � � <br /> Attach four(4)copies ol plans for proposed work• Draw lo cale and note the following as applicable: � - " <br /> • Properry Lines • Centerline of st�eet � <br /> • Outline and dimensions o1 a�l existing and • Indicate North ' <br />� proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed uttlities �� • Show measurements M <br /> W <br />� DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1. All calls for inspection shall be made 24 hrs.in advance•phone 259-881 5. � <br /> 2. All work shall be performed in accordance with Ihis permit and current Ciry ol Everett Design and Construction <br /> Standerds and Specitications. <br /> 3. Call Location Underground Service 4B hrs.before you dig.TOLL FREE NUMBER 1•E300-424•5555. � <br /> �. �-�- a��,-�...�����s d�,� //� O <br /> H <br /> �� <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDI110NS <br /> The undersigned owner/applicant hereby agrees to hold and save harm• - <br /> /J less the City of Everett Irom any and all claims for damages, costs, <br /> // / expenses, or causes of action that may �rise because oi installation r <br /> �� y__z�/� /� � � and main�enance of ihe improvemeni or other righ4ohway use heretn - � <br /> �L %L✓// " � applieA for and further agrees to remov.v same �pon nofice Irom the <br /> Approved Ior�Gonstruy ction G�^� Date � <br /> �� <br /> � Ciry and to replace public property damaged Ihereby. <br /> ��o-y� / / �/�P��� <br /> AL INSPECTION Date _(,-� V� �O/•��j <br /> Approved as Conshucted Signature of Applicant ��e <br /> evere[t PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITH'N <br /> � 3200 Cedar Street 180 DAYS OF OATE PERMIT IS ISSUED AND THEREAFTER I,, TO <br /> Everetl,WA 98201 BE DILIGENTI.Y PURSUED TO COMPLETIOIJ. THIS PERMIT MAY BF <br /> Phone: 259-8815 CANCELLE�BY THE LITY UPON ANY STOPPAGE OF WORK O�TF' <br /> PROJECT OVER 90 DAVS DURATION. <br /> � � <br />