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, . ^^ Public Works Pe�mll+ <br /> Uate i�/T�� <br /> - eme.oaa�.+ '+ua9d <br /> Application For <br /> PUBLlC WOR��S F�ERMIT PUEIicWorkfFee <br /> Tolal Fee s <br /> LessAD��FesP.itl S <br /> Dalance Due S— <br />� =�int or Type On;y <br /> Lund ren/:ia le 5130 Eter reen Wa #100 Everett 98203 259-•0199 <br /> Owner <br /> Mailing Address City Zip Phone <br /> Owner '— <br /> Applicanl <br /> Mailing Address City Lip Phone <br /> Describe Proposed Work _ <br /> � <br /> Project Address(if known} 51 EV L re n a 10 � <br /> O <br /> Attach four(4)copies of plans(or proposed work- Draw to scale antl note the followinc�as applicable: � <br /> • Property Lines • Centerline of street <br /> • Outline and dimensions ot all existing and � Indicate North <br /> proposed structures on ihe lol • Show any proposed grading changes <br /> � Exisling and proposed utllilies � Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> t.All cells tor inspection shall be made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be peAormed in accordance with this permit and curront City of Everett Design and Constructiun <br /> Standards and Specifir,atfons. � <br /> 3.Catl Location Underground Service 48 hrs.hefore you dig.TOLL FREE NUMBER 1-800-424'5555. <br /> ,/ , �S " �/' O <br /> ��/��<'c LC/^7/":.� �L:39,ic./` •"��^[ ��!'4�t.L�.ta.c/ <br /> 4 � <br /> �G �Z � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF COfJDITIONS <br /> 7he undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everett trom any and all claims for damages, costs, <br /> expenses, or causes of action that may arise because of install3lion <br /> � and maintenance ol the improvement or other right-u(•way use hereto <br /> applied lor and lurther agrees to remove same upon notice from the <br /> Approved for Construction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION Date Date <br /> Approved as Construcled Signalure oi ApPlicant <br /> WORK AUTHORIZED BY TH�S PERMIT MUST 8E STARTED WI7fiIN <br /> � PUBLICWORKSDEPARTMENT 18G DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everett,WA 98207 CANCCLLED BY THE CITY UPON ANY STOPPAGr OF WORK ON THIS <br /> Phone:259•8810 PROJECT OVER 90 DAYS DUI7ATION. <br />