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01 <br />Date.iy ` "7� Public works Permit• <br />Bldg. Dept. • w <br />Application For <br />PUBLIC WORKS PERMIT PubTotaWorksl Fee <br />Total <br />ea -- <br />•S - <br />Less Appl. Fee Paid $ <br />Balance Due <br />Print or Type Only <br />f�,t•/i7ii fEi� .� <br />��,2C--dioUSC/ s"A <br />�r'rA (t14/• 7965_ /Wr'sts:a /igC-ye- •Jr L-771 i/91 <br />Owner / Mailing? Address / City Zip Phone <br />• S//3.ytuon� �J �i - `� •S �, /l�Bnx Y `i +;— ii3.vit•m� �f � (::I f.. ?/S�9 <br />Applicant /Mailing Address City Zip Phone <br />Describe Proposed Work <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />O Property Lines O Centerline of street <br />O Outline and dimensions of all existing and O Indicate North <br />proposed structures on the lot O Show any proposeU grading changes <br />O Existing and proposed utilities O Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 5. <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 />��, C�J/tJS%c�GcTiU!-� �iGG i3F' D�✓c EnJ/TiY ti'�L-tr✓.el�S <br />T, Sc„c S'7doy DlJ/UG= Qy C45CaDE GE075.-/ dL- <br />fD�' iilis l�.eo�'E,EYf/ Gk/ AP.eiG 3.['0% i9�'S <br />Approved for Const ug . n Date <br />I <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />EverCedar Street <br />Everett, WV: 98201 <br />Phone: 259-831 5 <br />W <br />H <br />tttttttt� <br />0 <br />z <br />0 <br />0 <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 ri0;:t-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 />Signa re o; 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 <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />—f m <br />m <br />C 0 <br />m o <br />-t c <br />o m <br />2 Z1 <br />m <br />oz <br />n -t <br />r x <br />m <br />�m <br />x <br />m� <br />N <br />M r <br />�m <br />c LA <br />r— <br />m <br />a <br />X7 <br />4l <br />