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� � � <br /> H i <br /> Cy, H - <br /> t" H�G V� I <br /> Hx � <br /> FC O ���Jy� � .'^-� y:-�,:., <br /> O�H�O Date_�L� Publ¢WorksPorm <br /> N Application For eiae oeai.. � <br /> ��� PUBLIC WORKS PERMIT Pu�TotalFeeFco S <br /> �� g Less nop�Fee Paia s <br /> Baianca�ue $ _ <br /> �� a Print or Type Only . <br /> H <br /> � H <br /> g y y �—� ��,�� — �� ,i�C � _ <br /> H Owner Mailing Address Cit)• Zip Phone <br /> C� C�n <br /> C i t'� <br /> C+1 <br /> y � � Applican� Mailinc�Address City 2ip Phone <br /> -1F-�J[1 'IL��, `�{� G� � <br /> Describe Proposed Work �1 c T I � �^ u j,._�t` )L F <br /> 1 �/�r�1/� W <br /> Project Address(il known) 1 ���� ����Y(=C .f � � <br /> Attach four(4)wpies ol plans for pmUosed work� Draw to scale and note the lollowicg as applicable: � <br /> • Prope�ty Lines • Centerline ol street //^ <br /> • Outline and dimensions ol�II eaisting antl • Indicate North V� <br /> proposed strucW res on the lot • Show any proposed grading changes <br /> • Ezisting and proposed ulilities • Show�neasurements Y . <br /> � �ii <br /> � '�1 DO NOT WRITL BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1�' 1.All calls for inspec�ion shall be made 24 hrs.in advanr,e-phone 259•8810. � <br /> 2.All work shall b�pedormed in accordance with this permit and current City of Everetl Design and Construction <br /> '�� Standards and Specifications. <br /> 1 ' 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> � <br /> � � f� I��tt'� 0 <br /> fe c��'� 9/9�88 (�/� <br /> ��� �, <br /> _� <br /> �e a <br /> - <br /> _�'� ACKNOWLEDGEMENT OF CONDITIONS <br /> � The undersiqned owneqapplican[hereby agrees to hold and save harm� <br /> less the City ct Everett Irom any and all daims for damages, costs. <br /> � � eapenses, or causes of action thaf may arise because ol installatltin <br /> and mainlenance ol the improvement or other righ4ol-way use hereto <br /> applied lor and furlher a9rees lo remove same upon notice irom ihe <br /> Approved lor Construction Date City and to replace public property damaged thereby. <br />� <br /> FINAL INSPE.^.TION Date <br /> Approved as Consiructe� Sir,nature of Applicant Date <br /> evecett PUBLIC WURKS DEPARTMEN7 WORK AUTHORIZED BY THIS PERMI-i MUST BE STARTED WITHIN <br /> 0 32UOCedarStreet 180 DAYS OF DATE PErIMIT �S ISSIIED AND THERE�FTER IS TO <br /> Everett,WA9B201 RE JILIGENTLY PURSUED TO COMPLETION.THIS PERMI7 MAY BE <br /> Phone:259-8810 CANCELLED BY THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 O.�YS UUf;ATION. <br />