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Date��1/� � PubLc Wo�MSPeQrmp��5•�{.]-�—(/�{I_�� <br /> ' (31ep Dept•�! <br /> Application For <br /> PUBLIC WORKS PERMIT 7ubLCWorksFee <br /> TaISIFea S <br /> Less Apo�.Fce Pei� � <br /> Da�ance Ou� s <br /> Print or Type Only <br /> �l R� �� 'l�m��� l {�.� �f� �a ,�� qRao� <br /> Owner Maihnc�Addiess Gry 2ip Phone <br /> APP�i���� tdailing Atldress City Zip Phone <br /> Describe Proposed Work __, - I �` ^ + <br /> w <br /> Project Address(it known) � � � <br /> Attach low�4) copies oi plans for proposed work- Draw to scale and note the lollowin�as applicable: � <br /> • Property Lines • Centerline ot street � <br /> • Outline and dimensions ol all existing and • Indicate North <br /> proposed sVuctures 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 COND�TIOIJS <br /> 1.Ail calls lor ins�ection shall be made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work sh�ll be performed in accordance with this permit and current Ciry of Everett Oesign and Consiruclion <br /> �tandards and Specilications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL F�iEE NUMBER 1•800•424•5555. � <br /> \ C✓1 ��` r �4J �r_ O <br /> Gy // <br /> 7,/�_.��9 V♦ <br /> O <br /> a <br /> ACKNOWLEDGEAIENT OF CONDITIONS <br /> 1 he undersi�ned owneUapplicant nereby agrees to hold and save harm- <br /> I�ss the Gty ol EvereU Irom any and all claims lor damages, costs. <br /> expenses, or causes oi action that may arise because of installatien <br /> and mainlenance ol lhe improvement or olher •IghFOPway use hereto <br /> applied br and furlher a�rees to remove same upon notice Irom ihe <br /> Appwved lor Consiruction Date City and to replace public property damaged Ihereby. <br /> FINAL INSPECTION Dale Dale <br /> Approved as Conslructed Si9nature ol ApPllcant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARI'ED WITHIN <br /> ,.��i.�i.�� PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS iSSUED !WD THEREAFTER IS TO <br /> � 3200CedarSireet B[ DILIGENTLY PURSUED TO COMPLETIQN. THIS PERMIT MAY BE <br /> [veret�,WA 98201 CANCELLED BY THE CITY UPON ANV STOPPAGE Of WORK ON THIS <br /> I'i,;-n�•. :"s9-�iHlo PROJf_Cf OVER 90 DAVS DURATION. <br />