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Date�� <br />Application For <br />�u�Lic w��Ks PE�n�i-r <br />Print or Type Only <br />-7°G'Vct'�2t.�1 CMt <br />oW�e� -- <br />-� ����v� . 4� - <br />Applicanl <br />�Describe Proposed Work <br />� J�;�jJ'F-G1(,/�(d hTF <br />Project Address (il known) <br />( �Gv I%l!'-iafl�la Sr <br />Mailing Address <br />ylayU$ /3'� <br />Mailing Address <br />ti� <br />(�a f � w ,�i.l . <br />�s3d �/� <br />City <br />ruohc'r+oiMs Vormp� + <br />9149. DePI.• eS t% '( <br />i <br />PubLcWarksFee S <br />Totni Fee <br />Less ApO�� Fen PoiJ $ <br />Balpnci Oue $ _ <br />(�Jol 223 =i'��,� <br />Zip Phone <br />Zip Phone <br />%ZFsT-/xt,�. /:3U6C.1JlA1� Gi-' <br />Atlach four (4) copies o( plans for proposed work - Draw to scale and note the followin� as applicahle: <br />• Property Lines <br />• Outline and dimensions ol all eristing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PEr7M1T CONDITIONS <br />Y Cen�erline of streel <br />• Indicate North <br />• Show any proposed �rading chon�es <br />• Show measurements <br />1. P,II calls lor inspection stiall be made 2M1 hrs. in advance - phone 259•881 5. <br />2. 1111 work shall be performed in accordance with this permit and currenl City of Everet[ Desi9n and Construction <br />St,ndards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424•5555. <br />YU✓�'G� G c��r ,� �E.-�.���i <br />�C� <-�a�' issv.�y: ��3 <br />��� ! �" ',� �i�Di�r�r ���� <br />�� rJ/,C/� 8 C,/. <br />- - Ti.�i � �^c.yoi.: _ �! , <br />Conslruction <br />FINAL INSPECTION <br />Approved as Constructed <br />rvemtt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone: 253-8F115 <br />ACKNOWLEDGEMENT OF CONDITICNS <br />W <br />� <br />Y / <br />� <br />� <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less ihe City of Everett from any and all claims lor damages. costs. <br />expenses, or causes of :,ciion that may arise because ot in5tallahon <br />and mamtenance of !he improvement or other right-of-way use here�o <br />— applied for and further agreec to remove same upon notice from the <br />Date Cily anC to replace public property dama9ed thereby <br />Da�e <br />Siqnature of Applicant �a�e <br />WORK r.UTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE CILIGENTLY PURSUED TO COMPLETIUN. THIS �ERMIT MAV BE <br />CANCELLED BY THE CITY UPO�d ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />