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Uate� Pu�Lc\VodSPotmit+ �,[ /— ��� <br /> Application For 81ae.o°a�.` �7/�(.�7'�.S <br /> PUBLIC WORKS �ERMIT Pu�TolnlFeeF�� s _ <br /> Less A00�Fea Pa1E $ <br /> Bnlence0uo s �!0 CNA,e6E. <br /> Print or Type Only <br /> -i- LJ o�:s4- <br /> ` 1f/11 7�t�; .��PI�n ��� 7 (� �nr,r)n ,�r � t/( �`/'_/T �����a?(Y,� /� ��' <br /> Owner Mailing Address City Zip Phone <br /> ��,�c�������b .��-�����u� .c—v'A/P I��A �10 � 353 -/��� <br /> Applicar�t ailing Address City Zip Phone <br /> Describe Proposed Work ,�(.�IJ G(� ✓� �4 � C� �!'N ����n A � <br /> ��rn �'�«r..E� Eiv����l�r cr��,c� -�,E� ,, ��0 <br /> C/T O <br /> W <br /> Prole�t Address(if known) " � <br /> Attach four(4)copies of plans for proposed work- Draw to scale and note the tollowing as applicable: � <br /> 1 Property Lines • Centerline of streel � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed structures 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 /> 1. All calis for inspection shall be made 24 hrs. in advance• phone 259•PP1 5. � <br /> 2. All work shail be performed in accordance with this permit and currer 'ity of Evrrett Design and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> Tf.'iS 7,�Ai[Ek' �S io BE' t�'.c;tFo pN G�T` �i�rf1T- OF-l�✓Af/ O <br /> O,v A TEr;�i�oiZ.��c�ji .C�,S'S6S Dil,vNlr C'G,c,'S.-,r'luCiioiJ of' T//£ <br /> Ad Di r•aN. �" <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undc�rsigned owner/applicant herehy agrees to hold and save harm- <br /> less ihe City ot Everell Irom any ard all ciaims tor damages, costs. <br /> expenses, or causes of action that may arise because of installation <br /> � , fc��_ !�� �D —� and maintenance ot the improvement or other right•of-way use hereto <br /> O�vzrr�y applied for and further agrees to remove same upon notice trom the <br /> Approved lor Construci� GDate City and to rePlace Public proPerty damaged thereby. <br /> -� —< ��� � ����� �G�cf�o./9S1 <br /> FINAL I SPECTION ate � <br /> Approved as Constructed i9nature of A�:plicant Date <br /> everett PUBLIC WORKS CEPARTMENT WORK AUTHORIZED BY THIS PEfiMIT MUST BE STAR7ED WITHIN <br /> � 3200CedarStn;at 180 DAYS OF bc;fE PERMIT IS ISSUED AND THEREAi'Tci� IS TO <br /> Everelt,WA 982U1 BE DILIGENTLY f`URSUCD TO COMPLETION. THIS PERMIT MAY BF <br /> Phone: 259�8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />