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M�y <br />aqy <br />HEX <br />H� <br />jN Q <br />x <br />is V C) <br />H <br />'HYyy, H <br />rHH <br />rA H <br />ti [A <br />Cq Of <br />F3CCA <br />CAA <br />C 1 <br />a ! <br />Ise <br />! 'sl'llilli <br />Date/ Public Works Permit <br />Application For Bldg Dept.a <br />PUBLIC WORKS PERMIT P°blip Works Fee <br />Total Fee $ t <br />Less Appl. Fee Paid $ <br />L <br />S <br />Print or Type Only Balance Due <br />111r+i14n ?rlc2 a� FP.rn (Ld G✓arP/f 3SS—ten <br />Owner Mailing Address City Zip Phone <br />SKykymA (d, L;IINprs I14,93-3St' 4- SF F=kip - z�� �k7-/7 2_ <br />Applicant '1 Mailing Address I _C1iity Zip Phone <br />Describe Proposed Work i t d-pr ✓ (Add; k u n Xl SI t1g is o rr 4. 0VI6 <br />Project Address (if known) rr / /—Er'� <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 />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8810. <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. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800-424.5555. <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />'NORKS DEPARTMENT <br />3200C <br />I&L 3200 Cedar Street <br />Everett, VIA 98201 <br />Phone: 289.8810 <br />I <br />O <br />a <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 because 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 />City and to replace public property 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. THIS PERMIT MAY BE i <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS ` <br />PROJECT OVER 90 DAYS DURATION. <br />t <br />