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� <br /> �1 <br /> I� <br /> PuDlic Works Permlt• `-� �^S� <br /> Date ��� �'� <br /> oiao.oev��• <br /> Application For <br /> PUBLIC WORKS PERMIT Pu�IlcWorksFee g_ <br /> Totel Fea <br /> L¢se ApO�Fne PaiO $--�'— <br /> Balance Oue s��� �� <br /> Print or Type Only <br /> � �S � - 93�� <br /> �! 4-73x ��1L "�'� � <br /> n f71n.1 ff 1� l7 ( ���� �( CItY �iP Phone <br /> Owner Mailin�Address <br /> z <br /> 0 <br /> �i c: - - ,5 - T � <br /> `i /` r C i � i�Y'1 3�G 'J ` Phone m <br /> mailing Addre � Cdv Z�P <br /> Applicant • <br /> Describe ProPosed Work <br /> �� 4 E✓F - --�1 � ���r� e c� F� �-u� s ����a ,a���—� � � <br /> — .. —i <br /> n ��r' � �' m <br /> W m � <br /> Project Address(if knowN _— � _ .Z-i <br /> � m <br /> Attach four(4) copies of plens tor proposed work- Draw to scale and note the following as applicab e: Q = <br /> • Property Llnes • Centerline o(sVeet <br /> • Indicate Norih <br /> • Outline and dimensions of all exisling and � Show any proposeA 9rading chenges � _ <br /> proposed strv:tures on the lot � Show measurements M -� N <br /> • Existing an�proposed ulililies W < T <br /> DO NOT WRITE BELOW THIS LINE O � 3 <br /> -� m <br /> PEI7MIT CONDITIONS � _ . <br /> m � <br /> 1. Ah calls for inspection shall be made 2A hrs.in advance•pl�one 259•881 5. N <br /> 2. All work shall be performed in accordance with this permit and current Cily o( Everett Design and Construction o m <br /> Standerds and Specilicationa <br /> 3. Call Localion UnCerground Service 48 hrs. betore you dig.TOLL FREE NUMBER 1•500-424•5555. � m N <br /> z c� <br /> s� ���o �'l— q-!lJ � O � m <br /> / � ��— �'/ a <br /> z <br /> r � <br /> _ <br /> n <br /> z <br /> � � <br /> � <br /> O N <br /> z <br /> 0 <br /> � � <br /> c <br /> rn <br /> ACKNO�YLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the Ciry ot Everetl Irom any and all claims for damages, costs, <br /> - ' ezpenses, or causes ot action thal may arise because ot installation <br /> � /� / and maintenance of the improvement or olher right-of-way use hereto <br /> _ � � applied br and Wrlher agrees to remove same upon notice Irom ihe <br /> Appr ed for Cons ion <br /> Date City and 1� place Public property damaged thereby. <br /> 1 <br /> �' �—�-�6 � , � .: - -�-. <br /> Dale Date <br /> CFINAL INSPECTION Signature ot Ap icant <br /> Approved as Constructed WORK AUTHORIZED BY 7HIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PcRM1T IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Streel BE DILIGENTLY PURSUED TO COMPLET�ON. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 pROJECi OVER 90 DAYS DURATION. <br />