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� <br />q�H <br />9H(n <br />H�� <br />oxo <br />�UH�-0 <br />V1 H <br />C] O � <br />OH <br />��g <br />�I]Y �] <br />t"y� <br />Ny <br />g H <br />c� ti v� <br />���i+y <br />�H[n <br />HOv� <br />�� <br />Date_� <br />� � i <br />� PUBLIC <br />Print or Type Gnly <br />/3 2y zs -� <br />Application For � <br />WORKS P�RMIT <br />n <br />l� <br />� oa�oow <br />�_ o ��u7o�+ <br />i`n o.ro•om <br />� �, n � ,,. � <br />r'� '" I . ua ei <br />PuhLc Worxf Perm' � � / �, <br />. <br />BiOy DcO�� • <br />Pu�LCWo�MSFce 5 �!_ .� <br />To�al Fce U <br />Le55 FpP� Fee PmJ S •� <br />�/ ( �� <br />B.�tancc Due S �J�L� <br />�y � Mailing Address � � ����� ��n i�iC� Zip Phone <br />o cir ��-�:� <br />� k � ��a��� <br />Applicant Mailing Address City Zip Phone <br />��7 ` r._'• j��� <br />Describe Proposed Work ��'" �� J Q��—� � �"� �–� � <br />Projec� Address (if known) �O — <br />Attach four (4) copies of plans �or proposed work - Draw to scale and note the lollowin9 as applicable: <br />s Properry Lines • Centedine of sireet <br />s Outline and dimensions ol all existing and • Indicate North <br />proposed structures on ihe lot • Show any proposed grading changes <br />• Ezisting and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor inspeclion shall be made 2A hrs. in advance- phone 259•8810. <br />2. All wode shall be pedormed in accordance with Ihis permil and current Ciry ol Everet� Desiqn and Consiruction <br />Slandards and Specilicalions. <br />3. Call Location Underground Service 48 hrs. before you di9. TOLL /F-REE NUMBER 1-800•424•5555. <br />�% ���I/ GL�U^t'�� /GLtrS GI"c-:�/`�� S' �S 9 U <br />FINAL INSPEGTI9N' � <br />Approved as Con=:ructed <br />evcrett PUBLIC WORKS �EPARTMENT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone:259�8810 <br />S <br />Date <br />W <br />� <br />�w <br />_ / <br />11 <br />• <br />/�/� <br />V♦ <br />� <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersignetl owner/applicant hereby a9rees to hold antl save h. rm- <br />less Ihe Ciry of Everetl irom any and all claims lor damac�es, costs, <br />expenses, or causes ol action IhaLmay arise because of inslallation <br />and maintenance of tli�e improven nt or other righl-ol�way use hereto <br />applied lor and lurtt)�r a9recs t;remove sartie upon notice I�om the <br />City a 1 replace�(� blic pwp . iy dama9ed thereby. <br />A�� <br />, o /% ,�/ % � i ,� <br />SignaCuf� olAp`plic�mt j " � Date <br />WORK AUTHORIZED BY M 5 PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PE MIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVEH 90 DAYS DURATION. <br />�� <br />, <br />