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� <br /> r �' <br /> Date��/ J� � ' Pubhc Works Permit r � � <br /> Appiication For eido.oeo�.+ � <br /> PUBLIC WORKS PERMIT PUOToteFeefae s ,s��. <br /> Less ApO�Fea Peitl S �l�s� <br /> � Balance0ue S <br /> Print or Type Only �7��a <br /> �S'�—�633 Z <br /> Qi2 e�nk 5 ��s� . �`/7oG �a�ez S� ���� '�l��ao3 t���K - � <br /> Owner Mailing Address City Zip Phone � <br /> m <br /> Applicant Mailing Address City Zip Phone � � <br /> .. —� <br /> tn x <br /> m <br /> Deacribe Proposed Work c o <br /> p/��`- ��l2``—`�f/ �'� <br /> -�c <br /> o � <br /> w =� <br /> m <br /> 5���� �o.PcilT cJ.P. � .. <br /> Projact Address(if known) � <br /> a -+ <br /> Attach four(4)copies of plans for proposed work• Draw to scale and note the following as applicabl=: � ,.r.,,._., <br /> • Property Lines • Centerline of street � � N <br /> • Outline and dimensions oi all existing and • Indicete North CT <br /> proposed structures on the lot • Show any proposed greding changes �t Ay <br /> • Existing and proposed utllities • Show measurements � � m <br /> m .. <br /> DO NOT WFITE BELOW THIS LINE O y <br /> PERMIT CONDITIONS r <br /> C N <br /> 1. All calls tor inspeclion shall be made 24 hra in advance- phone 259•881 5. � m� <br /> 2. All work shell be performed in accordance with this permit and current City of Everett Design and Construction Z n <br /> Stendards and Specifications. :"�� <br /> 3. Call Locat(on Underground Service 48 hrs.6efore you dig.TOLL FREE NUMBER 1•500-424•5555. � p <br /> --1 <br /> O � <br /> z <br /> � <br /> x <br /> � M <br /> � <br /> � <br /> 0 <br /> -{ <br /> O � <br /> m <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> ,-� The undersigned owner/applicant hereby agrees to hold and save harm- <br /> — less the City of Everett irom any and all claims tor damages, costs, <br /> ` � expenses, or causes of action that may arise bacause of instaltation <br /> ��= 9 and maintenance of ihe improvemenl or other right-of-way use hereto <br /> r� applied for and further agrees to remove seme upon notice from the <br /> oved fo ons ction � �a�e City and to replace public property damaged thereby. <br /> ���f�'�� %� - s-�>- <br /> AL SPECTION Date " <br /> Approved as Constructed Signature of Applicant� Date <br /> everett PUBLIC WORKS DEPARTMENT WORK TUTHORIZED BY TH�S P MUST BE STARTED WITHIN <br /> 1b0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 C=dar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOFK ON THIS <br /> Phon=: 259-BB75 PROJECT OVER 90 DAYS DURATION. <br />