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Date II— .�� '��"I � N����.�::�.�.�,.,���,. <br /> AppliCation For ��9 �e� � —�� �3 <br /> PU�LIC WORKS PERMIT P°°:aWF�o�eC S <br /> Less Appl Fee PaiE 5 <br /> Oal�nco Ouc �u <br /> Print or Type Only <br /> 7c�rra �r�n�«s �z� rQ„�-t`` A �� e N� ��1�� I�PIJP✓UO ���/ �Fs3- 9S� <br /> Owner Mailing Addre s City Zip Phone <br /> �G�f1- (�nr�o� PD i`�a�l�!-kT'�_✓�na t�87�Oq ��� -33'(7 _ <br /> Applicant Ma�ling A dress City Lp Phone <br /> Describe Pr000sed Work ��jyr u�� I vN i�/n i/P ✓N P✓1� i..���y� � �i�/�%L(t l <br /> W <br /> Projr.ct Address(if knov�n) __���7J �U�P l��! �� � <br /> Atlsch four(4)copies ol plans for proposed work• Draw to scale and note the following as applicable: � <br /> • Properiy Lines . • Centerline rr streel � <br /> • Outline and dimensions of all existiny and • In�icate Norih <br /> proposed struclures on the lol • Show any proposnd grading changes <br /> • Ezisting and proposed utilities • Show measuremeNs � <br /> DO NOT WRITE BELOW THIS LIN[ � <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be made 24 lirs. in advan�e- phone 259•88i 5. � <br /> 2. All work shall be per(ormed in accordance with Ihis permit and wrreN City oF Everetl Design and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 I�rs. before you dig.TOLL FREE NUMBER 1•S00•424•5555. � <br /> 'En, v , ��.�"Bi O <br /> fU/3GiG u/O,c:.f-S fr�2MiT �./OT fi i� c1J � <br /> �� � <br /> � <br /> O <br /> � <br /> .4CKNOW�EDGEMENT OF CCNDITIONS <br /> The i�,ndersigned owner/applicant hereby agrees to hold and save harm- <br /> less the Ciry of Everett from any and all claims lor damages, costs, <br /> expenses, or causes of action that may arise because of instalt�tion <br /> and maintenance of the improvement or other right-oFway use hereto <br /> applied for and further agrees to remove same upon notice irom the <br /> Approved for Construdion Date City and to replace public properry damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Construcled Sic�nature ol Applicant Date <br /> PIfBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett 180 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFTER iS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERAIIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOHK ON THIS <br /> Pl�one: 259�8815 PROJECT OVER 90 DAYS DURATION. <br /> � <br />