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Date �'�Z� � — <br /> PuOlic Works Permit s <br /> Application For ame�oeoi.,� /� <br /> PUBLIC WORKS PERMIT Pu�licWorksFee <br /> Tolal Feo g <br /> less FOP�Feo Paid S <br /> Print or Type Only ea�a^=a o�� s <br /> <)r� ir n , Nr_1/ ►1i1 i �� N�l C ro,,,., /)�,� e I=�in�nrf 5sa0'3 ,�� �7�� <br /> Owner Mailing Ad res�s— Cit <br /> Y ZiP Pho�ie <br /> Cl��,� wl��,lp,� C��c1�„�h�� 3�a� ir�ajti AL s� F�tf- �8a�� _ <br /> 33 � si �6 � <br /> Applicant �— Mailing Addr�ss Ci:y Zip Phone � <br /> /'� �I m <br /> Describe Proposed Work _ l�O f A h P r�a X c� � P i t'7- ' ,�1� /`�V Q JQ u � M <br /> � -� � <br /> .. .-.r <br /> N S <br /> 0 <br /> m <br /> W = � <br /> m� <br /> Project Address pf known) Q C o m <br /> Attach four(4)copies ol plans for proposed work- Draw to scale and note ihe following as applicable: � s -=-1 <br /> • Propert Lines �^ <br /> Y • Centerline of street � Q = <br /> • Outiine and dimensions ot all existing and • Indicate North � <br /> proposed slructures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � �.r. � <br /> —1 N <br /> < <br /> DO NOT WRITE BELOW THIS LINE � <br /> O �a <br /> PERMIT CONDITIONS � m <br /> 1. All calls for inspection shall be made 24 hrs. in advance• phone 259•881 5. � _ <br /> m �-. <br /> 2. All work shall be perlormed in accordance with this permit and current City ol Evered Design and ConsVucHon �^ <br /> Standards and Specifications. o <br /> or <br /> 3. Call Location Underground Service 4B hrs.before you dig.TOLL FREE NUMBER 1-800•424•5555. � � y <br /> r3•t�' <br /> /(/G`� ���C�C �-r�`�/�,FS %'�c��%���: O �p <br /> ��.��,�.�� �-�' �, _ <br /> �j�s� _ <br /> � � <br /> _ <br /> .. <br /> O N <br /> Z <br /> O <br /> a � <br /> � <br /> m <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of 'cverett Irom any and all claims for damages, costs, <br /> expenses, or causes uf aGion that may arise because of installation <br /> and maintenance ol the improvement or other righFobway use hereto <br /> applied for and further agrees to remove same upon notice Irom the <br /> Approved for Construction Date Ciry and to replace public properry damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarStreet 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS 70 <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPIETION.TFIIS PERMIT MAY BE <br /> Phone:259-8875 CANCELLED BY THE CITY UPON ANY STOPPAGE Of WOFK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />