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Date 2 ZB 9/ Serl - -f , P 04�41 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Works Permit s <br />Bldg. Dept,* <br />Public Works Fee S <br />Total Fee <br />Less Appl. Fee Paid $ nn'' <br />Balance Due $ <br />Owner r Mailing Address City Zip Phone <br />IS�i rrfr°n/%vse - L7e�� 4�d Assoc. Alto - /1/0 "Afgve, .VE %/fi Pe Ae r <br />ebnsve far A".S Se/!e✓zee, Cc/a 10g,04 s V5yi4 .74/6 -9G20 <br />Mailing Address <br />City <br />Phone <br />Describe Proposed Work BOr'C Oni'�Or/rl� &"ezej grpd /r7S �a.�C COL'e- <br />�3 ze/eeexiir ol+o✓el Shovesr Lonv'o' ' in o' <br />W <br />Project Address (if known) 273/- Federal A✓e. <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE O <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrs. in advance - phone 259-881 O. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />`3. CallLocationUnderground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424.5555. <br />7 f/10dioE 4n/ 2d�fona� fryFfrc Control or tr4'04I O <br />qs al"ree kd 6y 70`�­ Pu6li o evohEt Q'eo t <br />a <br />l l <br />ACKNOWLEDGEMENT OF CONDITIONS <br />-� The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise hecause of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />Approveefl for Constru n Date City and to replace public property damaged thereby. <br />FINAL INSPECTION Date <br />Approved as Constructed Signature of c Date <br />everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />PUBLICW Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />3200 Cedar <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />Everett, 9 tree <br />Phone: 20 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />259-88 <br />PROJECT OVER 90 DAYS DURATION. <br />