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i <br /> i <br /> I <br /> pate=7=�..�0 I �,o�,�Wo,..Py��y�/ �Qy�/�30� <br /> Application For eWa�o•o���S�.' I � ✓o� ' <br /> PUBLIC WORKS pERMIT P°°°°W°��°°°° -- '� <br /> .a�r�Fea s i <br /> Z L)— S � Lass Appl Fe0 PaiO $ <br /> ✓ 3� � a.�.�.o�a s�— ', <br /> Print or Type Only , , <br /> Pas��d � i,,,,,� s i- yo � ; <br /> � �rP (�,��,. a6�aFf �7�'' A� � �V1Ull I� � <br /> wner Mailiny Adtlress City Zip Phona ' <br /> -�rr� ��-�a �Ig1���� ' <br /> Applicant Mailing AtlOress City Zip Phone <br /> Descnoe Proposed Work __ C T� � p�� � �1 r � � ^< < ��� �J <br /> W <br /> Project Atldress(if known) �' � <br /> Attach four�4)cop�es of Dlans ior proposed work- Draw to scaie and no�e the following as applicable: � <br /> � • Property Lioes • Centerline of street /A <br /> '� • Outline an0 dimensions of all existing and • Indicate North V� <br /> - proposed structures o�the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> � . DO NOT WRITE BELOW THIS LINE O '�, <br /> PERMIT CONDITIONS <br /> . t.Ail Calls tor inspeetion shall be made 2a hrs.in advance•phone 259-8810. � <br /> � 2.All work shall be pe•formed in accordance with this permit antl cunent City ot Everett Design artd Construction ��� <br /> .. StandarCs and Specificationa � <br /> � 3.Call Location Underground Service 48 hrs.before you di9.TOLL FREE NUMBER 1•800�4245555. � �� <br /> i <br /> � i <br /> � I <br /> � <br /> a <br /> � <br /> � � ACKNOWIEDGEMENTOFCONDITIONS . <br /> ,.� . The undersigned owner/applicant hereby agrees to hold and save harm- ', <br /> less the City of Everett from any and all claims for tlamages. costs, <br /> . � ezpense , or causes of action that may arise because ot installation �. <br /> i/Z Qp and ma' tenance of the improvement or other right�of-way use hereto �i <br /> T � applie .tor and further agrees ro remove same upon notice from the <br /> P.oprovaC for Constr _ - ate City � to replace public properry dam ed thereby. �� <br /> /G-/1 '�f . _7' G �\ � (.! �. <br /> FINAL INSPECTIJN Date � <br /> Approved as Constructed Signature of Applicant Oate <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTE� Wi7HIN <br /> everettl PUBLICWORKSDEPARTMENT 1g0 D4YS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILI�ENTLY PURSUED TO COMPLETION.TH15 PERMIT MAY BE <br /> Everott WA 9920i CP.NCELLED BV THE CITV UPON ANV STOPPAGE OF WORK ON THIS <br /> Phone:259•8810 PROJECT OVER 90 DAVS DURATION. <br /> I <br />