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Date�—V V PuOLeWo�ksPe�m� B8-8^-Y7' <br /> eim.oeoi.• � C,' / <br /> App�ication For <br /> PUBL.IC WORKS PERM�T PubToloFeeFee S <br /> Less ADP��Fee Paid S--�-' �j <br /> Dalance Dua � I � <br /> Print or Type Only <br /> G,-.; /�"�,r--I- �� 1 � ��..��Jl�l ���'I�S lQ� <br /> ti�i� r I t�Tr' � Phone <br /> Owner Y Mailing Address City Z�P <br /> Applicant PAaiiing Address Ci�Y Zip Phone <br /> �%�i i1�J�r-��<`)l� , <br /> Describe Proposed Work �-- <br /> W <br /> Project Address(if known) ��`-' ��-���� � <br /> � <br /> Attacn lour(4)copies ot plans lor proposed work-Draw to scale and note Ihe following as applica��le: � <br /> • Property Lines • Centerline of slreet <br /> • Outline and dimensions of all existing and � Indicate North <br /> proposed structures on the lot • Shuw any proposed gradirg changes <br /> • Existiny and proposed utdities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> t.All calls for inspection shall be made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be pertormed in accordance:�n!h ihis permit and current Ciry of Everetl Design and Construction <br /> Standards and Specil;cations. � <br /> 3.Call Location Undergrcund Service 48 hrs.before you dig.TOLL FREE NUMBER 1-B00•424•5555. <br /> c�i O�Lr,�f.� � L<JATE'G' /n9�•C/ %/J B�' Coit/STiPC.L�TLrO O <br /> la�'.e /9i9�i�rJl�i�/� Plif'•tJ1' .Z��TE'O .3 —7-i'��,. (f�TTACH�D> � <br /> �/POL/GlJ.Vi �S %P �.PG✓�'_:1d� ��/�/�oQ/�ls.'/r�G� N <br /> C�!/AQANi� r� 6vC'.E'.�. � <br /> � <br /> ACKNOWLEDGEMF.IJT OF CONOITIONS <br /> Tne undersigned ownedapplicanl hereby t c�rees to hold and save harm- <br /> less Ihe CitY of Everetl irom any and all claims lor dam�ges, costs, <br /> expenses, or causes ol action thal m�y ar;se 6ec����e of installation <br /> -�� j" � and maintenance of the improvement or othur righ a-way use hereto <br /> � apPlied lor and further agrees to r.mova sai�e up��� nolice Irom the <br /> roved for I n�st Date �iry nd to r lace pubii property Camaged tiimeby. <br /> � ' s'=i-�� ,f�.�, �'��� 9 ,r�.��e t� _ <br /> FINAL INS�ECTION Date - � Date <br /> Approved as Constructed S' ature ol Applicanl <br /> RK AUTHORI2ED BY THIS pERM1T MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPAR7MENT CO DAYS OF DATE PERM1IIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CederStreet BE DIL�GENTLY PURSUED TO COMFLETION. THIS PERMIT MAY BE <br /> Everclt,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�0810 PROJECT OVLR 90 DAYS DURATION. <br />