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� ��3 <br />Date`� � <br />Appli 3tion For <br />Pll�LIC WO�":S PERMIT <br />Print or Type Oniy <br />fv� ��)� � R 1 �� �-� <br />� Owner <br />�'IGr�ih ar1�}kuci <br />Applicant <br />Describe Proposed Work y--' <br />�1G r-�C v .- � <br />Project Address (if known) <br />�� <br />in �n. '%�3 !lO f�� f�j� <br />Mailing Address <br />cC�, �`i-�VL- <br />Public Works Permit • "� ' O � <br />Bltlg. Dep�. x <br />PUCIic'No�ks FOe r'- <br />Tolalfeo 5 � � ' � � — <br />Less Appl Fee Paltl S � G� <br />Balanco Due S �� " � � <br />J.__r f [orJL <br />City Zip <br />3c����u� cl��uy <br />�J ��� C1J i.� '— �� <br />_ (l —��ti.,i�c..c -C <br />Attach tour (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of strest <br />o Outline and dimensions of all existing and • Indicate North <br />proposed slructures on the lot • Show any proposed grading changes <br />s Existing and prop�sed utilities • Show measurements <br />�� � 5 - o y �/_3 <br />Phone <br />yss-2a85 <br />Phone <br />1 c Yl <br />PERIAIT CONDITIONS <br />1. All calis (or inspeclion shall be maae 24 hrs. in ativance - phone 259•881 5. <br />2. All work shall be pe�lormed in accordance with this permit and current Ciry of Everetl Design and Construction <br />Slandards and Specifications. <br />3. Call Location Under�round Service 48 hrs. 6efore you dig. TOLL FREE NUM� -500-424-5555. <br />k �. _� � �N�-�,��� c���s <br />�{. w o.� o o. �( co( �� (� �/�/ <br />�ry�.tu 5'�Z-�3 C'PCG.rd/�.�` ��G1�''C.fS 0.��X <br />Q � V <br />� �,r9s•-� ��� <br />��INAL INSPI <br />Approved as <br />everett <br />� <br />h <br />PUBLIC lh"ORKS DEPARTIv1ENT <br />3200 �edar Streel <br />Everett, WA 98201 <br />Phone:259-8815 <br />'./„7-f3 <br />� / Date <br />S��j <br />Date <br />W <br />H <br />� <br />� <br />� <br />O <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less ihe City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action lhat may arise because of installation <br />and maintenance of the improvement or olher righl-of-way use here[o <br />applied for and turther agrees to remove same upon notice trom the <br />Ciry and to replace public property damaged iherehy. <br />� <br />/ti�.��/� � � ��� �, ��J, <br />SignaWre of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. _' <br />