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, .; <br /> 3�^,� PupLCWorA�Peemn. �� �+_?��—� / <br /> Date�� ;"� -�9-rZZcj.S ] _ <br /> uiae oeo� • <br /> Applica�ion For <br /> PUBLIC WORKS P�:RMIT Pub7c�WF�sFee $ --_ <br /> Less M�o� Fne Pa�a $ — <br /> ��ri <br /> v�ia���o�o S 2f. <br /> Print or Type Only <br /> groo�,/' ��J Cu+r��f' 2�/U lo�t"l�iia N ��.s/r.f�L� �l�dLd 77(0 -�5�,�_ <br /> Owner Mading Address City Zip Phone <br /> �� .,�11 — _— <br /> Applicant Maihng Addrrss Gry Zip Phone <br /> Descnbe Proposed Work _�I� n, 1 Sid� �SK���✓ rPJidPA P — <br /> - W <br /> Project Address(il known) �T'�I C"t`'��'�Cf�1J � <br /> Attach four(4)copies of pians lor proposed work- Draw to scale and note the lollowiny as applicable: � <br /> • Property Lines • Centerline of siree� � <br /> • Outline and dimensions of all existing antl • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Ezisting and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shal�be made 24 hrs.in aLvance•phone 2SJ•ES�O. � <br /> 2.All wn�k shali be padormed in accordance with this permit and current City of Everetl Design and Construction <br /> 8!andards and Specifications. <br /> 3.Call Location Underground Service 46 hrs.before you dig.TOLL FREE NUMBER 1-R00•424•5555. � <br />'' O <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> ,��(,� The undersiyned owner/applicant here�y agrees to hold anA save harm� <br /> less the Ciry of Everet� Irom any and all claims for damages, costs. <br /> expenses, or causes of action that may arise because of installation <br /> � �� ,, l Cc, , � , �C.� and maintenance of Ihe improvement or othei ri�ht-o4way use hereto <br /> � l� � applied lor and further agrees to remove same upon notice Irom the <br /> Approved lor onstr tion - Dale Ciry and to replace public property damaged thureby. <br /> i. _ <br /> l<</ ��_�.;:-,e � <br /> FINAL INSPECTION Date - " � <br /> Approved as Constructed <br /> ignature o�AppG nl Date <br /> WORK AUTHORI2ED BY THIS ERMIT MUST BE STARTED N.'ITHIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett.WA 99201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURATION. <br />