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1 <br /> Date�9 P������Ymrks Fermit• !` <br /> 1 ( / <br /> uinu o�n�.. ��,l7 Z— . <br /> AppliCa�ion For <br /> PUBLIC WORKS PER�VIIT Pu�TotlFeeFL� §_ , <br /> Less An��.Fae Pai� S �' <br /> n <br /> BalanceDue $ �'7�`� 'i <br /> Print or Type Only <br /> _ tN —� I <br /> Ow er Mailing Address Ciry ip Phone <br /> � -� .�, -� ;4„- I N. /P�l�.��� ��l Nc� F, ve�/�e�e �'309 ��-��I4 C�39 0� ��� I <br /> Applicant —� Madmg ddress G°ity Zip Phone <br /> Describe ProPosed Work " � 1� >G l����II/CLy� �T�<� ��`ri--'"�!��l���lr/�0� <br /> W <br /> Project Address lit known) �n��,� ��'�'� `"-`�""' ��""` � ~ <br /> ii ; <br /> Atlach tour(4)copies of plans fnr proposed work� Draw to scale 2nd note the following as applicable: � <br /> • Property Lines • Centerline of stree� � <br /> • Outline and dimensions of all exisling and • Indicate Norih <br /> proposeti siructures on tlie lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremenis /M <br /> W <br /> DO NOT WRITE BELOW THIS LINE � O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in advo�ce-phone 259•8810. � <br /> 2.All wo�k shall be peAormed in accordance with this permit and current City of Everett Design and Construction <br /> , Standards and Specificalions. <br /> 3.Call Localion Undergrcund Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800-424•5555. � <br /> � UlL<:���"� Sc<��- —•.�['tc.��', ��tL./ �Lc. � � /�_ls�%', tic'% O <br /> � [�/� /� ^ <br /> / �1.L[:.� C'..� v��cZl�7��'M �.�C ,CLi L.' . <br /> /r / ///-��� / � <br /> J� �[-I/ .�� Fa!^-� `/ .["�V.� �4-'.'l l/�Ll .fC't:�C��.(`[_/: _! � <br /> J � / <br /> ��..Z��� �/ 5�/� (�l,f{L{��✓> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applican�hereby agrees to hold and save harm- I <br /> less the City of Everetl irom any and all claims for damages, costs. <br /> expenses, or causes of aclion that may aiise because o( installation <br /> � ' and maintenance ot the improvemenl or other right-ol-way use hereto <br /> . ` �, f <br /> �:.�� !=�/�•'Z'��� �—j���3� applie for and fur�her agrees to remove same upon notice Irom the <br /> Approved lor ConsVuc ion/�. Date City ai lo r�lac�pu17\1ic pr �erty dama�ed thereby. <br /> '� r<=� '�' ,' . /� � - / / <br /> . //' ��, � / � � � ; ,_ <br /> L <br /> FINAL INSFECTION - Date � <br /> Approved as Constructed Sit�na re ol App� nt- a�e <br /> WORK AUTHORIZED-f� fHIS PERMIT MUST BE STARTE WITHIN <br /> everet: PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 CeJar Street BE DILIGENTLY PURSUED TO COh1PLETION. THIS PERMIT MAY BE <br /> Everett,WA 9B2U7 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURATICN. i� <br /> � <br />