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Date� <br />� <br />Applicallon For <br />PUBLIC iNORKS PERMIT <br />Print or Type Only <br />OD/yH-�EiY � <br />Owner <br />�.yG' <br />Appllcant <br />Describe Proposed Woik <br />oN /1-i,-v ar <br />Pro�ect Address (it known) <br />.0 � J ��' <br />Mailing Address <br />Mailing Address <br />�7snw��-� <br />� <br />Public Workg Permi� s U V�� <br />BIdB� Dapt r �� <br />Puelic worxs Fee s <br />Total Fae <br />Lass PpO� Foe Paid S <br />BalanceUue .$ �� <br />y�� <br />�� �s'.s �/s' 7�.� �� <br />/545—.5'E. E"vE,PE7T. <br />aN �%�,rrrr h�� i� li.r y� <br />Attach four (4) copies of plans (or proposed work - Draw to scale and note the following as app�ica6le: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />Phone <br />rnone <br />PERMII' CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All work shall be performed in accordance wi:h this permit and current City of Everett Uesign and Conslruction <br />Standards end Specifications <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE iVUMBER 1•800•424-5555. <br />j� T BE COrr/ST.QUGTEO �E,� ��pp,ep�/EO <br />PoT P�9n/ t��J7E'1� 5-�0-86' <br />^'� <br />Approved as Constructed v <br />everett, PUBLIC WORKS DEPARTAI <br />� I 3200 Cedar Street <br />JEverett, WH 98201 <br />Phone: 259•887 5 <br />ACKNOWLEDGEMENT OF CONUITIONS <br />W <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City ol Everett from any and all claims for damages, costs, <br />exFenses, or causes of action that may 2rise because ot Installation <br />2nd maintenance of lhe improvement or other righFof•way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thareby. <br />�i�.., �" 1„ �,..,-�,-� Cv-Z7-P� C�� <br />Sic�natu;e of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED ANO THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY dE <br />CANCELLED BY THE CITY UPON ANY STOPPACac OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />