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c�� �� � <br /> Date�1�L OD a�oi��w<,�„aa,m . C�—•3`�� <br /> ApDlication For e�aa oeai u I� <br /> PUBLIC WORKS PERMIT P°°;oaFeBFBe s ----- _ f <br /> i ess aooi.Fee aa�,� S � <br /> Print o� Type Only ea�a��a o�e s �O��-- i'' <br /> I <br /> �tC'1C l-��� Iq I �� O,�l"�t2T}��12Y -Q�<►�JI�T���980 ► I ,'+ <br /> Owner MaiVing Address Ciry � Zip Phone <br /> ���y�1/���p �O � v /l.J � i <br /> pplicant Mailing Atldress Cih, Zip Phone �� <br /> Describe Pr�posed Work � � ��� ' I �-�. rZ`�\-C� � 7 1 � ��V ' <br /> ProjectAtldresslifknown) y9o� - ,�a,�k. .�a����. W <br /> Attach�our(4)copies of plans for p�oposed work- Draw to scale and�ote the following as applicable: � <br /> • Property Lines • Centerline ot streei � <br /> • Outline and tlimensions of all existing and • Indicat?North <br /> proposed StruCtures On thP lot • Show any proposetl grading changes <br /> • Existing and proposed utilities • Show measurements � � � <br /> DO NOT WRITE BELOW THIS LINE O ' <br /> PERMITCONDITIONS � ' <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•8870. � <br /> 2.All work shall be performed in accortlance with this permit and carrent Ciry of Evere}t Design and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you d:g.TOLL FREE NUMBER 1-800-424-5555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> � ACKNOWLEDGFMENT OF CONDITIONS <br />�\ <br /> The undersigned owneriapplicant hereby ag:ees to hold antl save harm- <br /> less the Ci�y of Everett irom any and all claims �or tlamages. cosis. <br /> . �� expenses, or causes of action tnat may arise because of installation <br /> B�9 Bg and maintenanc^ of Ihe improvemeM or other rigM-of-way use hereto <br /> appiied for and further agrees to remcve same upon notice frum the <br /> Aporoved tor Construcf Date City artd to replace py6�ic propeny damaged thereby. <br /> �! /U/2 -� I p ^� <br /> FINAL INSPECTION Date �'� 6'-/l�� <br /> Approved as Constructed S nature ot�ppli n Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY TNIS PEFMIT MUST BE STARTED WITH�N <br /> O 3200CedarStreet 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFIER IS TO <br /> EveretC WA98201 BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Phone:259�8810 CANCELLED BV��.-rIE CITV UPON ANl'S70pPAGE C1F WORK ON THIti <br /> PROJECT OVER 90 DAYS DURATION. <br />