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Date �_6� Pu01ic Woeks Paimil x `�`�' � <br /> i � <br /> Application For eiee�oopi s o <br /> PUBLIC WORKS PERMIT PueTotal��aFee 5 ��7._ <br /> � Less ApO�Fee Paid $ —�� <br /> 8alanco Oue .S <br /> Print or Type Only , <br /> .�N✓�'` �78 <br /> C IT`/d'31��J K l9v l D— �5��� �c�. � u�1nlcJovc( 9�d.3H_ 7��.� <br /> Owner Alailing Address City 2ip Phone <br /> �n1� u � r�cJ-FiTi= ci�S �/ /,� ffeG�r77` 9��0 / �.�s�-�Y7/ <br /> Applicant � Mailing Address � City Zip Phone <br /> Describe Proposed Work ��� r +r��� L�°""�� <br /> — � <br /> ProJecl Address(if known) ��G�� �%- � ' ` � <br /> Attach tour(4)copies of plans for proposed work- Draw to scale and note the following as applicable: � <br /> • Property Lines • Cented�ne of sireet � <br /> • Outline and dimensions ot all existing and • Indicate Norih <br /> proposed structures on lhe lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements /�/� • <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMII CONOITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance•phone 259-881 5. � <br /> 2. All wor;;shall be pertormed in accordance with this permit and current Ciry of Everett Design and Construction <br /> Standards and Specifications <br /> 3. Call Location Underground Service 48 hrs. belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> �. �.br G=-/ � ra-.�e }�/Gi,-� cicc f-�� �/Z�83 O <br /> / <br /> � <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/app�icant hereby agrees to hold and save harm- <br /> less the Cily of Everett from any and all claims for damages, costs, <br /> � expenses, or causes of action that may arise because of installation <br /> � � J � and maintenance of the improvement or olher right-of•way use hereto <br /> plied�f a d furiher agrees to remove same upon notice Irom the <br /> Appr��(or G�ns ruction Date Ciry n o pl ce lic proparty damaged thereby. <br /> F�� /Y.c� ����� �7 4 <br /> Gmll Dat�e � ___�.. .�'_!// �_ <br /> Approved as Constructed ` � ign� ure d 1{pplic nt Date <br /> everett FUBLIC WORKS �' 4RTMENT NVORK AU ORI2GD BY THIS PERMIT MUST 8E S7ARTED �NITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEft IS TO <br /> � 3200 CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE � <br /> Everett,WA�38201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORI<ON THIS <br /> Phono: 259-8815 PROJECT OVER 90 DAYS DURATION. , <br /> � <br /> � �— � <br />