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� <br /> ' '1 <br /> . �8te �� '�� •�`♦ PuElit Wod�Pvr�il• <br /> Applicatlon For emo�oeo�.• �y /-36,C.5— <br /> PUBUC WORKS PERMIT PuhliCWork�FN <br /> Tol�l Fee s <br /> ' Lasa�oo�Fav PslO S � <br /> B�I�nte Oue S <br /> Print or Type Only <br /> l=-/� �< o�.�s�e-7`� �l9os G��n�wac�d �., �-- as� - �� �o <br /> Owner Mailing Address City Zip Phone <br /> \� _ <br /> 0 <br /> Appli aM Mailing Addrass City Zip Phone 'i <br /> .. <br /> C') <br /> Deacrlbe Proposed Work aYi��� ' S�42A c..4� m <br /> .. .. <br /> --1 TI <br /> �..� ...� <br /> ' 1 W "_ <br /> 0 <br /> m <br /> ProJect Address(if known) y � �� � �t'��� �w � � m � <br /> o �a <br /> Attach tour(4)copiea of plens to�proposed work• Draw to scale and note the following as appiicable: � � Z <br /> • Property Lines • Centerline of street � x -1 <br /> • Outline and dimeneions of ell exlsting and • Indicate North m .. <br /> praposed structures en the lot • Shaw eny proposed grading chenges Q = <br /> c <br /> • Ezisting and proposed utilitles • Shaw measurements � � _ <br /> 00 NOT WRITE BELOW THIS LINE � N <br /> PEHMITCONDITIONS O TA> <br /> 1. hll cells for inspection shall be made 24 hrs. in advance• phone 259•8B1 5. � � m <br /> 2, qll work ahell be pertormed in accordance with this permit and current City of Everett Design and Construction = <br /> Standards end Specificatlona m v� <br /> 3. Call Locetlon Underground Service 48 hrs.bsfore you dig.TOLL FREE NUMBER 1-800•424-5555. � o r <br /> c vmi <br /> O m y <br /> .im <br /> a <br /> � p <br /> � <br /> 2 <br /> a <br /> z <br /> r M � O ._. <br /> , ' p e ��5,��rP � <br /> � a Z <br /> 0 <br /> � � <br /> / .. <br /> o ye "�'_ m <br /> �C.. 7-I i �� <br /> CKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicanl hereby agrees to hoid and save harm- <br /> less the City of Everett from any and all claims for dameges, cosls, <br /> ezpenses, or causes of action that may arise because ol instal�etlon <br /> and meintenance of ihe improvement or other right-of-way use hereto <br /> applied for and turther agrees to remove same upon notice Irom the <br /> Approved for Construction Date City and to repiace public property c'amaged thereby. <br /> FINAL INSPECTION Date <br /> Approved es Constructed Signalure of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AU7HORIZED BY THIS PERMIT MUS7 BE STARTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEFEAFTER IS TO <br /> Everett.WA 98201 BE DILIGENTLY PURSUEO TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259•8815 CANCEI.LED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 50 DAYS DURATION. <br /> L- J <br />