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i � <br /> I <br /> ; <br /> i <br /> __ .,,r..i,. -.^-----s--�—'---------� - ---'— - '. _..----------�--�/�-,I i <br /> i .. .. I' , ;,, , .,.I � .�... . .. , ; ; . , . . . . i ,, <br /> y /] / I <br /> 1 _ ��� � '- � _ J GF � <br /> � � . � r-r 9 f o <br /> Date�o '' Publ¢Wo�hs Pnrm� • <br /> I ' _- <br /> BItlB�Deo��• <br /> I Applicatlon For _ <br /> � P��BLIC WORK� PERMIT Pueiicwo�ksPee $ <br /> Tolal Fee <br /> , Less Rnol Fee Pam S <br /> � 5�� <br /> Ba1an<e Due <br /> I <br /> � Print or Type Only , <br /> , ; <br /> � ��� °1 ��� t/ Il i � /Wi 1� /(JIIJI `J( ��D C I6'��/1 � /ni(Q� �� <br /> i Owner <br /> M iN Addr s City Lp Phone <br /> � L� I � <br /> ' Applicant Mailing Address Ciry � Zip Phone i <br /> � Describe Proposed Work �� <br /> W <br /> ProjectAddresslifknown) '�� 1 , F�1 v�l' ��v� ' ' �^ � � <br /> I Attach four(4)copies ot p�ans for proposed work- Draw to scale and nole lhe lollowing as app�icable: � � <br /> � • Properry Lines <br /> • Cenlerline of sireet ���40:2 � <br /> ♦Outline and dimensions ol all exisling and • Indicale North G�_DG 856?.00 <br /> i proposed structures on the lot • Show any proposed gradi�[ieanges SS�.�1 <br /> � Ezisting and proposed wili�ies • Show measuremems Y�CH £110.00 M <br /> iii <br /> I DO NOT WRITE BELOW THIS LINE O <br /> i 01•:UWS' 420.00 <br /> � PE ITCONDITIONS k'100D6814 <br /> i� 1.Ail alls tor inspection shall be made 24 hrs.in advance-phone 259•881 O. Wr.TER 5650.00 � <br /> 2.All ork shall be performed in accordance with this permit and current Cit,�ol Everett Desig��Constr�rbp <br /> I 5 ndards and Specifications. �yu1�7 ul � <br /> ' 3. all Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800'114 71-S�rS81J.OD <br /> E SRCH 34.50 O <br /> CHFCI; :^c�63.90 <br /> � � <br /> � <br /> O <br /> a <br /> �. U`Y � ACKNOWLEDGEMENTUFCONDITIONS <br /> � V The undersigned owneqapplicant hereby a9rees to hold and savr.harm• <br /> � . less the City ol Everelt Irom any and all c�aims for damages. costs. <br /> ' expenses, or r_::aes ol action that may arise because of installaLon <br /> (� !�� � ('Y\1 and maintenence of the improvement or othei right•o4way use hereto I <br /> 1� X �l-"�- J/7/"' applied for �rd lurther agrees to remove same upon notice Irom the <br /> Approved for Constr c // � e C�!y nd to re ece pub�ic�roperty d�d thereby. <br /> �12� � r.. <br /> �a �ii-so � <br /> ^ Date <br /> FINAL INSPECTION � nature�ol Applicant Date <br /> Approved as Constructed <br /> � ORK AUTHORIZED BY THIS PERMIT MUST BE STARTED \VITHIN <br /> everett PL'BLIC WORKS DEPAR7MENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFiER Ifi TO <br /> � 3200Ceda�Street � BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BC- <br /> Everett.WA98201 CANCELLED BY THE CITY UPON ANY$TOPPAGE OF WORK O�: THIS <br /> Phone:259•8810 PROJECT OVER 90 DAYS DURATION. ' j <br /> . . . -- � -. _ _ -. - -� --- - ---� <br /> � <br />