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� r 'l <br /> � <br /> Date� �" � PuElic Worka Permll+ `�� <br /> Application For eiea.oen�.a <br /> PUBLIC WORKS PERMIT PU�TotalFeoFee S 20— - <br /> � — Less AOa�Fee Peid $ � � <br /> 1 <br /> Print or Type Only ���.��Q��,9� ea�a��eo�a S ?D' P� <br /> �� �. <br /> ��A • �'T� P►�rKl£ f'p� 86x 213� �v�Ew�r�, wd . q$zp3_3s�-�o73 <br /> Owner Mailing Address City Zip Phone <br /> �d {n � <br /> Applicant Mailing Address City Zip Phone <br /> n v -}' e (� I (/ <br /> Deacnbe roposed Work <br /> �laeK Tol �h �� [ ��� �� / dN�� h /� 0 � a -�- � /r� � F� � r I ��• <br /> i/I��Ea- ,ba.rr► Q OF (=�.or�cs Vnarll�i. <br /> , <br /> W <br /> Pro�ect Address(if known) � <br /> Attach four(4)copies of plans for proposed work• Draw to scale and note the following as applicable: � <br /> • Property Lines • Centerline of slreet � <br /> � Outline and dimenslons of ell existing and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � �� <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIOIJS � <br /> 1. All calls for inspection shail be made 24 hrs. in advance• phone 259•881 5. � <br /> 2. All work shall be performed in accordar•e with this permit and current City ot 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 /> Se� �4��,pr.� �,�etch . , O <br /> C'a��s[rlfe fipci /ri�ffi C��y :IS�sP Pc f o�, �� {� pa��iE�g, <br /> 1 � <br /> � � � <br /> � y � <br /> � a � <br /> � , <br /> ACKNOWLEDGEMENT Or CONDITIONS <br /> The undersigned owner/app�icant hereby agrees to hold and save harm- <br /> Iess the City ol Everett Irom any and all claims lor damages, costs, <br /> � expenses, or causes ol action that acisa because ot installation <br /> � �_O� and maintenance of the improveme o other riqht-ohway use hereto <br /> �� applied lor an iher agr s. o m ve same upon nolia: irom ti:�a � <br /> 'J Ap r ved for Consiruc ion / � Date City and to re lac bli o rt d a9ed thereby. �' <br /> t q <br /> � ,�t���- •�'�,1'�5/ _ �7 ` '-CJ.� <br /> i FINAL INSPECTION Date � � ' '' � y <br /> Approved as Constructed Signature ol Applicant Date <br /> � everett F'UBLIC WOflKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND f1iEREAFTER IS TO <br /> i � 5200 Cedar Street <br /> � Everelt,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259•8815 CANCELIED BY THE CITV UPON ANY STOPPAGE OF WORK ON TIi�S ,,,� <br /> ; PROJECT OVER 90 D.4YS DURATION. <br /> � <br /> � <br /> i , J <br /> ; _ .r..i.�. <br />