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_� _ <br /> Date �„h�,�wo��s r�,���. <br /> � eiae oeo� , />'7 �tQ' <br /> Application For �T'-'�-''-- <br /> PUBLIC WORKS PERMIT P°°:aWFa�F°a 3 — <br /> �ess noo�.vea vam 5 — <br /> Balanc�Due s <br /> Print or Type Only <br /> �l�.��O�.AL.--—�L�D� l�nr.��r ti.�.Go�a FvPieF� q.c � ,�� 3y�F -an9� <br /> Owne�r MaiHr��dress Cdy Zip Phone <br /> Sp ►n+- — <br /> Applicant Mailing Address City 2ip Phone <br /> Describe Proposed Work �� ���p�(�rr� � fM — �VYiN4 /Na . !�>n'h'�H� f�y--.•jE+�-- <br /> V <br /> Project Address(if known) T°a� ���1'i��M �ANO- _ � <br /> � <br /> Attach four�4)copies ot plans for proposed work- Draw lo scale and note the lollowing as applicable: � <br /> � Property Lines • Centedine of street � <br /> � Outiine and dimensions of all existing and • Indicale Noilli <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 calls for inspection shall be made 24 hrs. in advance- phone 259•881 5. � <br /> 2. All work shall be pertormed in accordance with this permit and current City ol Everett Design and Construction <br /> StanderAs and Specifications. <br /> 3. Call Locati�n Underground Service 48 hrs.betore you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> �C/�S'G/C GVO�.CS �E/1h�i% .r/OT O <br /> �`�'j C.-�i/�',_�',O � <br /> �/Z�B� � <br /> �� O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City ol Everetl from any and all claims lor damages, costs, <br /> expenses, or causes of action that may arise because ot installation <br /> and mainlenancn ot the improvemen! or other righl�ohway use herelo <br /> � applied lor and further a�rees �o remove same upon notice Irom the <br /> Approved for Construction Date Ciry and lo replace public properry damaged the�eby. <br /> � FINAL INSPECTION Date — <br /> Approved as Consiructed Signature ol Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST 8E STARTED WITHIN <br /> � 3200 Cedar Slreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98207 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT A4AY BE <br /> Phone: 259�8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />