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J <br /> Y <br /> Date�{Cl � Pu�lic Woiks Pcrmit a � <br /> ! ' Bldp.Dapt+�G/ �� <br /> Application For / " <br /> P�1B1_IC W�RKS PERMiT PubTotaFeeFeo § <br /> Less Appl.fee Paia S-- — <br /> Balance Due � <br /> Print or Type Only <br /> �,�,---�-��'�-�P� Mailin9Atldiess City Zip Phona <br /> ��Q�i1/'/ .Q.r.J �(�,J '-l�i��/�� 0�'`�,�Q�' ��_�_ <br /> Applicunt Mailinc�Address Ctlq •.ip Phone <br /> a �/ - • /,� � � ,, D <br /> � iTrP/.uAii �J �I/I1,I�fi�1 1�(� �,'�(� <br /> Deacribe Proposed Work �,-N._._.��'l����- � � <br /> [ W <br /> Project Address(if knov.•n) -Lt�/ � � �n'�p��T �u � <br /> / <br /> Attach four�4)copies of plans lor proposed work- Draw lo scale an note the(ollowing as applicable: � � <br /> • Property Lines ! Centerline of stree� � <br /> • Outline and dimensions ot all existing and • Indicate North <br /> proposed structures on the Int • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT�NRITE BGLO\N THfS LINE � <br /> PERMIT CONDITIONS <br /> 1. All calls for in�;pection shall be made 24 hrs.in advance- phone 259•881 5. � <br /> 2. All work shall oe performed in accordance with thic permit and curre�t City of Everett Design and Consiruction <br /> Standaids and Specifications. <br /> 3. Call Location Undere,round Service 48 hrs. before you dig.TOLL FHEE NUMBER 1-800-424•555�. � <br /> ���� ,�C 'F��'iC C�c>/;Cs ��'=i'��T �E�F'9�i.c��G' � <br /> ,�L�J . � <br /> � /�j7��G 'ir i <br /> � � <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everelt from any and all claims for dama�es. costs, <br /> expr.nses, or causes of action that may arise because of installatiun <br /> and maint?nance ot ihe ic�provemenl or olher right-o4way use hereto <br /> applied for and furlher a�rees to remove same upon notice from lhe <br /> Approved tor ConsVuclion Date City and te replace public properry damaged thereby. <br /> FINAL INSPECTION Date Date <br /> Approved as Censtructed Signature of Applicant <br /> WORK AUTHONI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everer �UBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TU <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Evere!t,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259•8875 PROJECT OVER 90 DAVS DURATION. <br />