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� <br /> � � <br /> - - -- -_ _ _ --- ---- - <br /> _ _ <br /> _ _. ._ i <br /> � �95-/�G � <br /> PuElic WatW Permii• <br /> i �ate ' � eio�.oacc. i <br /> � Application For <br /> � � PUBLIC WORKS PERMIT PubTotalFeeFPe 5 I <br /> � Less ApO�Fee Paid S / �j7 I <br /> ' Balance Due a ` ��� /{ � <br /> Print or Type Only i <br /> I � <br /> - �� �� ' . _�III� / � , / � �� ��' ; ,;'s - 7 ✓ s� I <br /> .n�: �' / c i , ti i� il�a - 1. i b / / <br /> I Owner.' MailingAddress City Zip Phone i <br /> z <br /> � 7 �� , I r , .� <^ ) ' -�- ' r / � .-�-� <br /> ' � � � � � � c � ' 1-- � � . i t �/ � � �5� � i .� , � <br /> . _ APPlicant' J Phone � � <br /> Mailing Address ���Y Z�P rn <br /> � � ��. � � � � , � ; `�r'� � 1/ i/,r" ' ^� <br /> I Describe Proposed Work , � -'� '� <br /> ... --� <br /> N S <br /> 0 <br /> m <br /> � W �� � o <br /> mo <br /> i � <br /> � Pro�ect Address pt known) � j � � f- �"� � � �r '���� <br /> / , J �'I �/ � � � m <br /> J _ m � <br /> � .Adach��ur(4;copies of plans for proposed work-Draw to�cale and note the following as applicable: � <br /> � � � property Lines • Centerline of sireel � Q = <br /> ��, • indicate North , � <br /> r - • Outline and diniensions of all existing and r Show any proposed grading changes � _ <br /> � proposeA siructures on the lot � � <br /> � • Existing and proposed utilities • Show measurements /� �i � N <br /> W � �, <br /> �' DO NOT WRITE BELOW THIS LINE O �' <br /> � � � a <br /> ' -t m <br /> �� pEP.MiT CONDITIONS � �?� � <br /> �� 1. All calls�ar inspection shall ta made 24 hrs. in advance- phone 259•881 5. � <br /> � 2. All work shall be performed in accordance with this permit and currenl City of Everett Design and Construction I o r <br /> � Standard`s and�pecifications � � r^ <br /> ', 3. Call Location Underground Service 48 hrs.bebre you dig.TOLL FREE NUMBER 1•800•424•5555. � I e �^ <br /> 3 tn <br /> m <br /> i z c� <br /> ,� . T.eUGT CUl/-c-ic O I � m <br /> �", i�ol�Gil'G.vT SNGLc Ca�JS C��if'S � i z <br /> /�it/D S�OE�✓<iG.� ALoit/G EdE/'�.C�"EN �'Jy' C/v/L � -a <br /> /,�/Oi?K TO �E DCSiG.v�-p 8` it ,�EU�SrF.c�� EidG✓i✓EC.c � � <br /> I �� � � <br /> � ,S A ����i�oNr stia�� �o��io� ,� o�����<�:�e.vcF O � Z <br /> �J�� ,�o�4.�TEE �.E' ��/3o F�• Sr�EFr a , a <br /> m <br /> �r�P,eovCl"��TS. <br /> / /rYI/��o�/�/�C.J T /l%�,%j'T �c ���J � %� c' i-="� <br /> . (p. c+ �-� �� ACKNOWLEDGEMENTOFCONDITIONS <br /> � /!:�'��,` j� /,SJv��C` ✓F The undersigneC owner/"applicant hereby agrees to hold and save harm- � <br /> � less the City ol Everett Irom any and all claims for damages, costs, <br /> �' �. _- expenses, or causes ol action that may arise because ol inslallalion <br /> �, �"' �� �; .�� �s and maintenance ot lhe improvement or other righl-ol-way use hereto <br /> �, ; / a�•plied for ard luriher agrees to remove same upon notice trom tbe <br /> i Approved tQi.�onstruc lon � �� Dale Ci'y and t� replace public properry damaged thereby. <br /> � .._--��-� � �� /v �� - <br /> � Date _'� -� . :.� � . ��'� � . , , ��_ . <br /> INA SP CTIO Sigr.atura of Applicant "" ; Date <br /> ' Approved as Constructed <br /> WORKAUTHORIZED BY THIS PER!'�T MUST BE STARTED WITHIN li <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS IS�JED AND THEREAfTER IS TO ,� <br /> � � 3200 Cedar Streel � �����f'iCi'�i� BE DILIGE��TLY PURSUED TO COMPLETION. THIS PERMI7 MAY BE <br /> Everetl,WA 98201 CANCELLED Br THE GTY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8815 UF ��«�������� PROJECT OVER 90 DAYS DURATION. <br />