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/ <br /> � � � z � -z.� -� �p� �3 � � � d � 9� /�B <br /> � �e�� <br /> � Date rks Perm • <br /> ia o o� + <br /> . d APPlication For , <br /> �' ' 1 'J i�9 <br /> y�� PUBLIC WORKS PERMIT ` ' ' 1 P�blicWodsFee 3Z�6 — <br /> TotalFee $= <br /> .......... ......................�......................�� <br /> K n CITY OF fV�RE ess Aoo��Fec Pa�ia g��— <br /> p �p �aianceDuc $ ��� <br /> titl�AI Print or Type Only Public Wo►kS Depf, <br /> w <br /> ��� ���j�'Q_ 1�"f'�`Y'� �� ��� Y'Pl��"? �( `� 1 9 r§��FX-� <br /> ��"� Mailing HdAress Ciry dp ��hone <br /> �A ty Owr.er <br /> �Q• Ae! ,_�/ <br /> ~� !��'r r Madm Address Ciry Zi0 Phone � <br /> �F� Ap0licant 9 <br /> ~ 'Pu� �i7� �t �P�L'E�2�E-1-i(-� � <br /> w � <br /> �"� Desaibe Proposed Work <br /> �� <br /> �� c W <br /> —�"---�—'"� Project Address(if known) /V �Z� L�'�'� — � w � � � <br /> � � Attach lour(4)copies of plans for proposed work• Draw to scale and nole ihe following as applicable: � <br /> � • Property Lines • Centerline ot street � <br /> •Outline and Cimensions of all existing antl • Indicate North <br /> proposed struciures on the lot • Show any proposetl grading changes <br /> • Ezisting and proposed utilities • Show measurements M <br /> W <br /> � � DO NOT WRITE BELO\N THIS LINE O <br /> 1 ; PERMIT CONDITIONS 259-8810. . <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone � <br /> � 2.All work shall be performed in accordance with this permit and current City of Everett Design and Consiruction <br /> '�1 Standards and Specifica�ions. <br /> 3.Call Localion Underground Service 48 hrs.before you dig.TOLL Fi1EE NUMBER 1•800-424•5555. � <br /> �-� .�. /�.�,, �,�,��,.P��/r �� �� �-Z-9� O <br /> - <br /> ii H <br /> �- V� <br /> -r O <br /> ' a <br /> %i <br /> �' ACKNOWLEDGEMENT OF GONDITIONS <br /> ' The undersigned owner/applicant hereby agrees to hold and save hari�- <br /> less the Ciry of Everett fmm any and all claims br damages, costs, <br /> � expenses, or causes of action that may arise because of installation <br /> a O and maintenance of the improvement or other riGht-ot�way use herr,to <br /> applied for and turther agrees to remove same upon nolice Irom the <br /> qpp r on cf Date City and to replace public pro erty damaged thereby. <br /> i � 4 � 1 � (y � <br /> FI AL NSPE ! �a1e Dale <br /> Approved as Constructed Sig ature ol Applicant � <br /> WORK AUTHORIZED BY THIS PEAMIT MUST BE START D WITHIN <br /> everett PUBLICWORKSDEPAR7MENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED 'O GOMPLETION.THIS PERMIT MAY BE <br /> Everett,WA98201 CANCELLED BY THF CITY UPON ANY STOPPAGE OF WORK 01J THIS <br /> Phone:259�8810 pROJECT OVER 90 DAYS DURATION. <br />