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Date <br />Applicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />PUEIit Work� p��mit • <br />ewa o.o� . _ <br />Pu01ic Worlu Fo <br />Tol�l Fa� � -- <br />Lu� Appl Fa� PaiE Z-�� <br />Ba4nc• oua S ��_ <br />Plan Check No: C 47609 <br />Appllcat.Date: 02/2g�g5 SEPA <br />Owner Job Addre: 391b FEDERAI, AVE <br />Owner: LOFSTROM E Phone <br />PropoeednUeee SINGLE FAMILy gESiDENCE <br />Applicant Desc. of Work: <br />LAUNDRY/BATH ADDITION <br />Phone <br />Descrlbe Proposed Work OFFICE SET-�JOB SET <br />APpRVD FOR PERMIT: DATE� <br />���� BY_ <br />ProJect Address (if known) <br />Attach four (4) copfes of plans for proposed work- Draw to scale and note the following as applicable: <br />� Property Linas • Centerline of street <br />� Outline and dimensions of all existfng and <br />proposed structures on the lof ���d��ate North <br />• Exlsting and propased utllities • Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspectbn shall be made 24 hrs, in advance - phone 259�$g�p, <br />2. All work ahall be performed in axordance with this permft and current City o} Everett Design and Construction <br />Standards end Spec(flcailona <br />3. Call Locatlon Underpround SeMce 48 hrs. before yau dig. TOLL FREE NUMBER 1-$00-4245555. <br />�'UBLIC WOqKS PEPMIT <br />hO{�f �jiEOUIREP <br />`�Y_._.1ii' <br />,AT£.3 .�.sM._. <br />Approved for Constructfon Date <br />FINAL INSPECTION <br />Approved as Constructed Date <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Sheet <br />Everett, WA g8201 <br />Phone: 259•8810 <br />W <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/appifcant hereby agrees to hold and save harm- <br />less the Cqy of Everett from any and all clafms for damageS costs, <br />expenses, or causes of action that may ar(se because of installation <br />and ma:ntenance of the improvement or other right-of-way use heretp <br />applied lor and further agrees to remove same upon notice from the <br />Cfty and to reptace public proparty damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS .TO <br />BE DILIGENTLY PURSUED TO COMPLETION. iHIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DqYS DURATION. <br />