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�' <br /> / <br /> Datesz�v L— 3'�2�� � Publie Wo�ke Po�mil O—�S3 <br /> App�ication For ema.oeo�.y <br /> � PUELIC WORKS PERMIT P°o°�W°,k,Fea - <br /> Total Fee S <br /> Le59 A00�Fee Pal� S� <br /> Balance Due S��� <br /> Print or Type Only �/5� J/� <br /> "7�/' <br /> ��CI �n�5�'� '71 S ���^��/7 �v� /�Q 11�'rf7V��/? �/-� �'Tro/ <br /> Owner Mailing�9ddress City Zip Phone <br /> �1P%art2�,��r �4���l�rs�Ar,� ,�k a ��1� �����i� <br /> Applicant Mailing Address City Zip Phone �� <br /> Describe Proposed Work �?�.�� �c�p� <br /> W <br /> Project Address(il known) �Z �-C U I �- �I� � � - <br /> Attach four(4) copies of plans lor proposed work-Draw to scale and note the lollowing as applicable: �� <br /> • Properry Lines • Centerline of street 0.�/26/90 3:49FM OOORN0671 � <br /> • Outiine and dimensions ol all existing and � Indicate North <br /> proposed structures on the lof • Show any proposed�rading chariges <br /> • Existing and proposed utilities • Show measurements �p��l� � <br /> DO NOT WRITE BELOW THIS LINE CF{ECf: f�OO.SO <br /> PERMIT CONDITIONS Q <br /> 1.AII calls for inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shell be peAormed in accordance with this permit and current City ot Everett Desian 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 /> � � 5�bJ L-12 �c�o c �:Y ia� -ro a� co�i sT�a��.�-�� O <br /> i f�S Ftl-z. r\T�R"�R1� t�-�).!S �AT�1c� / 1 - 3- •`�a_ � <br /> ' � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF COVDITIONS <br /> The undersigned owner/applicant hereby agn�es to hold and save harm• <br /> less the City of Everett Irom any and all claims lor damages, costs. <br /> expenses, or causes ol action that may arise because of installation <br /> v��C,�� � ��`—P� and mainlenance of the improvement or other right-of•way use hereto <br /> Approved lor Co uction Date applied lor and further agrees to remove same upon nolice Irom the <br /> � City a to replac public property damaged thereby. <br /> ���`� /C'! /_JO � G3�/ \ <br /> FINAL INSPECTION Date <br /> Approved as Constructed nature of App��cant Dale <br /> everett PUBL�C WORKS DEPARTMENT ORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarSueet 180 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett WA98201 BE DILIGEN7LY PURSUED TO COMPLETION. TIiIS PERMIT h1AY BG <br /> Phone:259•8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON TIiIS <br /> PROJECT OVER 90 DAYS DURATION. <br />