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Dat�a�_,L�/ V Pu�lit Woihs Perm�� � — ��� <br /> ' eiav.oeo�.� <br /> Application For <br /> PUBLIC WORKS PERMIT Pu��To�FaeFco $ - <br /> Less Aoo� Foc Peia S�— <br /> Balan<oDun s ��� <br /> Print or Type Only <br /> � «nm���'.�n�o�1�1 ��� �-s�aa <br /> ner Mailing Address '.�tY Zip Phone <br /> 4 5�.��I��� �J ��I �I�"�� �"l u� '� �������f I� <br /> ( Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work S�" �-�{- ✓�H�(`�� <br /> � W <br /> Projecl Address(il known) � � <br /> Attach tour(4) coples of plans lor proposed work- Draw to scale and note Ihe tollowing as applicable: � <br /> • Property Lines • Cenlerline ol ctreet � <br /> A Outline and dimensions of all existin9 and • Indicate Norih <br /> � proposed slructures 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 CONDITIONS <br /> I 1.All calls far inspeclion shall be made 24 hrs.in advance•phone 259-BS10. � <br /> 2.All work shell be pedormed in acwrdance with this permit and current City of Everett Design and Construction <br /> Standazds and Specificalions. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> � O <br /> � <br /> � <br /> Cdd,� To B� .oa.✓� v�2 O <br /> !�<U�SE,t� SiTE PL.q.r/ ��G�v�� /� <br /> /_ _ G d. g� Ii <br /> (P <br /> X��.� - ��c . �G�,n„� <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> �J The cndersigned owner/applicant hereby a�rees to hold and save harm• <br /> less lhe Clty of Everett irom any and all claims lor damages, costs. <br /> i � � � � /�/Q8 expense5, or cau5es ot aclion that may arise because ol insfallation <br /> ���� �� and main�enance ol lhe improvement or other righFol•w2y use hereto <br /> �ari� � app�igd lor and lurther agrees to remove same upon notice Irom the <br /> Approved lor Go trur,tion Date City and to replace publlC properly tlamac�ed Ihereby. <br /> �� �i�-l?J-�� _� . <br /> /�ft a � <br /> FINALINSPECTION Date �^� �'�/�' �-�'�'��'�"�' <br /> Approved as Constructed Signatur� of Applicant Date <br /> WORK AUTIiORIZED BY THIS PERMI7 MUST BE STAFTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUtD AND THEREAFTER IS TO <br /> � 3200Cedar!'ireet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Everett.WA9tl201 CANCELLED BY Th'E GTY UPON ANY STOPPPGE OF WORK ON THIS <br /> Phone:259�8810 pROJECT OVER 90 DAVS DURATION. <br />