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i <br /> Date�� 7 � � r�nu, wo�ks v�� i <br /> 1 BI�q.Oeo��y y <br /> Application For <br /> PUBL.fC WORKS PERMIT PubTotolfae�ee $ <br /> Less AO�L Fee Peitl $ <br /> Bnlnnco Duc $ <br /> Print or Type Only. <br /> ��� C1,�L:--�,V.�►'1 � I"7 �1/ �l f�� 9F��_- <br /> Owner Mailing Address Gity 7_ip Phono <br /> .��.��� �I�r� � �A(��'���fi'1 1� ► r'��� n� �-�(�I_ <br /> Applicant Mailing P�ddress Cit1' �— ZiP Phone <br /> Describe Propos=�d Work ��_�� JF� <br /> W <br /> Proiect Address(if knuwn) �`- � � <br /> Attach fcur(4)copias of plans lor proposed work• Draw to scale and nole ihe following as applicable: � <br /> • Property Lines . • Centerline of streel � <br /> • Outline and dimensions ot all existing �nd • Indicate North <br /> proposed stniclures on the lot • Show any proposed grading changes <br /> • Fxisting and proAosed utilities • Show measurements � <br /> DO NOT WR�TE BGL01N THIS LINE � <br /> � PERMIT CONDITIONS <br /> 1. All calls(or inspection shell be made 24 hrs. in advance•phone 259•8815. � <br /> 2. All work shall be performed in accordznce with this permit and current City ot Everett Design and Constructlon <br /> Standards and Specitications. <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> l"UBGIC Gr/0.�.�.' P�=�m,T �n.- .f'.�' 3 ��-i-;97 O <br /> C�U%�e`�'��� <br /> c� � <br /> � <br /> O <br /> a <br /> � ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/apP�icant hereby agreec to hold and save harm- <br /> I�ss the City of Everett Gom any and all claims lor damages, costs, <br /> expenses, or causes of action that may arise because of installation <br /> and mainten•r_nce of ihe improvemenl or other righl-of-way use hereto <br /> applied for and further agrees to remove same upon notice from the <br /> Approved tor Conslruction Date Ciry and to replace public propeiiy dama9ed thereby. <br /> PINAL INSPECTION Dale \\`� -- ' `�il�'�� , v�� �-� I <br /> Approved as Co�siructed Signature of Applicant Date <br /> everett PU6LIC WORKS DEPARTMENT WORK AUTHORI?ED BY THIS PERMIT MUST BE STAFTED WITh�IN <br /> 180 DAYS UF UATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street gF DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED B`f THE CI1Y UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259•8815 pNOJECT OVER 90 DAYS DURATION. <br />