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� <br /> � <br /> Date� Pubirc Wow.e Permd• �`r'7 � /p <br /> ewc nem.. -Hr��-i-/— <br /> Applicalion For <br /> PUBLIC WORKS PERMIT P°°°`""""°° �- <br /> Tota1 Fee s <br /> LenMn�.Fee�am S <br /> 6aiance�ue S <br /> Print or Type Only <br /> SG 3 <br /> !1 i "_►. . r?„l�.„.0..:�- ('o-.n �?741- /�"t 1Y-�`E _�q I r„e O 9��o / ��n-711..70 <br /> � Owner M �Hng Address Ci�y 2ip Phone <br /> � HI � st r2k � �,�.�- ld-a.6�' as�- 4a�r) <br /> T uY.r r Fa��.t Ao� �0/ St21 r � <br /> Appl�cant Ida�hng Atldress Cdy Lp Phone <br /> �[ <br /> Describe Pr000sed Work <br /> W <br /> Prolect AdAress(il known� 39is- c'o�a� �//�� � <br /> Atlach four(4)copies ol plans lor proposed work- Draw to scale and note the lollnwing as applicable: � <br /> • Property Lines • Cen�erline ol street � <br /> • OutGne and dimensions ol all existing and • Indicale North <br /> proposed structures on the Ict • Show any proposed gradiny changes <br /> • Existing and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> i.All calls for inspection shall be made 24 hrs.in advance•phone 259-8810. � <br /> 2.All work shatl be pe:iormed in accordance with this permil and wrrent City ol Everett De�ign and Construction <br /> Standards and Specificalions. <br /> 3.Call Location Underground Service 48 hrs.betore you dig.TOLL FREE NUM6ER 1•800-424•5555. � <br /> `� �.,e,- cr�ro�-����r�.�r.s �t�'d 7-Z-� -£ag O <br /> r/ <br /> � <br /> � <br /> � <br /> a <br /> ACKNOWL[DGCMENT OF CONDITIONS <br /> 1he undersigned owner/apphcanl hereby agrees to hold and save harm- <br /> - less tlie City ol Everetl from any and all claims for tlamages. costs, <br /> � expenses. or causes ol action that may arise because of instaliation <br /> �� and maintenance o1 ihe impwvemer,t or other righl-ol-way use herelo <br /> �- �- applied lor and furiher agrees to remove same upon notice Irom ihe <br /> Ap 6ve lor�bnstru n� �a1e Ci and to repjaGe pu �c pr pert tla�ged thereby. <br /> � �ISM°� cb1s�,. �s��,.r����J <br /> . . /p_lY-� � � <br /> FINAL INSPECTION Da�e � Date <br /> Approved as Constructed Signa re ol AppliCant <br /> WORh AUTIiORIZLD THIS PERMIT MUST BE STARTED WI7HIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAVS OF DATE PERMIT IS ISSUED AND TIiEREAFTEP IS TO <br /> � 3200Cedar Sireet BE DIUGENT�Y PURSUED TO COMPLETION. THIS PERMiT IdAV BE <br /> Everett,WA 98201 CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-BB70 PROJECT OVER 90 DAYS�URATION. <br />