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HC�� <br />q�H <br />�Hv� <br />H�� <br />�H� <br />�p�H <br />�a� <br />Hl7 <br />OH <br />H�g <br />�1]Y (7 <br />t,y� <br />HH <br />� y <br />C] t7 � <br />���+ <br />yy <br />H O C/� <br />�� <br />Date�l=3`/9 �! t"'"`� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />�' � Publ¢ Waekn Pmmit x <br />Blag pu01. ! ���7 � /— / <br />. —i,-��l_-�1G/�(�� <br />r�nr� wo�k: r�: <br />Talal Fw 5 — <br />Less.4V�� Fee Paid $ _ <br />Balanc� Uuo � — <br />�77/-9D�0 <br />M�,e�/YloNr oM�'Y :�ss -��o� <br />Applicant Mailing Address Cdy Zip Phone <br />�escribe Proposed Work � <br />�A �5 A -���;�-�;��i n �e �- I"Yl a <br />Prolecl Address (if known) _l�SJ _ <br />Attach ;our (4) copies ol plans for pwposetl work - C.aw to scale and note Ihe lollowinc� as apP���able: <br />• Property Lines <br />• Outline and dimensions of all ezisting and <br />proposed strucW res on Ihe lot <br />• Exis�in� and proposed utilities <br />e Centedine of street <br />• Indicate North <br />• Show any pmPosed gradinq changes <br />• Show measurements <br />PERMITCONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 1�i9•ii810. <br />2. All work shall be pedormed in accordance wilh this permi� and ci��rent City of Everet� Design and Conslruction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. betcre you dig. TOLL FREE NUMBtR �•800•4`L4•:i555. <br />r�v2�eeied�,z%yi,/��i,.»-.c7� ��U[r7= ,�•�qGec:k-d� <br />b <br />Approved lor Gonstruction Date <br />FINAL INSPEC710N Dale <br />Approved as Construc�ed <br />everetl PUBLIC WORK3 DEPARTMENT <br />� 3200 Cedar Sircel <br />Everetl. WA 98201 <br />� Phone:259�8810 <br />�.�°i3o�'3- <br />�z �i-90 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />�w <br />s / <br />� L�" <br />• <br />♦�^ <br />V♦ <br />� <br />LL <br />The undersigned ownedapplicant hereby a9rees to hold and save hanm <br />less Ihe City of Everett irom any and all claims lor damages, costs, <br />ezpenses, or causes ol action that may arise because ol installation <br />and mainlenance ot Ihe improvement or olher ric�hPol�way use hereto <br />applir.d lor and �urther agrees �o remove same upon nolice Irom the <br />City and lo replace public pronerry damaged Ihereby. <br />Si9nature ol Applicant Dale <br />WORK AUTHURIZED BY THIS PEFiMIT MUST BE STnRTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TC <br />BE DILIGENI'LY PURSUEO TO COMPLETION. THIS PERMIT h1FY BE <br />CANCELLED UY THE GTY UPON ANY STOPFAGE OF WORK ON TNIS <br />PROJ[CT OVER 90 DAYS DURATION. <br />�c.^. <br />