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�6 <br />� <br />Application For <br />PI�BLIC WORKS PERMIT <br />Print or Type Only <br />PUEbc WorM� Pprmtl • `�' � —/ ��� <br />Biap. Deo�. • � � �%�v � <br />PublicWoik�Fee a <br />Tclai Fee <br />Lev Pppl iee Pa�E S <br />Baienceoue S �Q��� <br />� .G� srE��s �J.9, 99�s8 (s� - 2ozs- <br />City Zip Phone <br />SqmE As .9Bo vE <br />Applicant Mailing Address City 2ip Phone <br />Deacribe Proposed Work �O�1Si.Br/GT s. F_ �, _ <br />Project Address (il known) 7�9— CO'� <br />.007 "�`/le <br />Attach four (4) copies of plens icr proposed work • Draw to Sca�e and note the foilowing as applicable: <br />• Property Lines • Centerline of sireel <br />• Outlic r. and dimensions ol all exlsting and • Indicate Norlh <br />proposed strucWres on Ihe �ot • Show any proposed grading changes <br />� Exis�ing and propuseu utililies •,' Sow measuremenls <br />PERMIY GONDITIONS <br />1. All calls lor Inspec ticn she�l M mad^ 24 hrs. in advance • phone 259•8815. <br />2. All work shalt be peAormetl i� accordance with this permil ane current City ol Everett Design and Construction <br />�tenderds eno SpeclHcations <br />3. Call Loeation Underground Service 48 hrs. tefore you dig. TUV. FRE!° NUMBER 1-800•424•5555. <br />�- .q�y <br />Te' <br />CU,c'6� G�r1E.:� o,e S���ciac,E. <br />F%�LiCFr�✓T S//AGL <br />L�'i�C�G gn/T <br />`.' <br />everett PUBLIC WORKS DEPARTM�NT <br />� 3200 Cetlar Streel <br />Everetl. WA 98201 <br />Phone: 259•8815 <br />� <br />� <br />� <br />� <br />O <br />� <br />aP��,�GEo �f' V� <br />Be ,FE�,c ycEo ay iy� O <br />� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicanl hereby agrees to hold and save harm- <br />less Ihe City ol Everetl Irom any and all claims lur damagea, costs, <br />expenses, or causes ol action thet may arise because of �nstaltetion <br />anU mainlenance of the improvement or other righbobway use hereto <br />epplled lor and furiher agrees to remove same upon nutice trom 1Fe <br />City and to replace public properry demaged thereby. <br />_�C ^i �//�.li'l� <br />Signature ot Applicant Dete <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITFIIN <br />180 DAVS OF DATE PERMIT IS ISSUEO AND THEREAFTER IS i0 <br />BE DILIGENTLV PURSUED TO CO'SPLETION. THIS PERMIT MAY 3E <br />CANCELLED DY THE CIN UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVEF 90 DAYS DURATION. <br />