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r <br />Date_��8 � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or T,ype Only <br />DUr?t«�r �--e�..,�. <br />Ow r <br />£ �_c <br />Applican� <br />Describe Proposed Work . <br />L� t(-•t. i-'1� L ( <br />r-„�r,r<.tc.— � <br />i„r�a ���� <br />Prolect Address (if known) <br />Public Wo�ks Permil + �`� � <br />aiaa. oam.. <br />Public Wo�ka Fea s <br />Tolel Fea <br />Lesa AOo� Fee PaiE S <br />ea�a��a o�a s aG; O[� <br />qS3 i�a6w��v C��-�- �i gLt3 <br />Mailing <br />� <br />� �zs <br />2Sz— gBtiU <br />Phone <br />�f�� �.B:,� ��� 9�z� a <br />City Z�P <br />i. � la) �'c't-r A tll 1) _ I) L_L <br />Attech four (4) copies of plans for proposed work - Draw to scale �nd note Ihe tollowing as applicable: <br />• Property Lines • Centedine ol street <br />• Outline and dimensions of all existing and • �ndicate North <br />pioposed struclures on the lot • Show any proposed grading changes <br />• Existing and Proposed utilities • Show measuremenis <br />. <br />� � � �- r L-�z.� <br />Phone <br />W <br />PERMIT CONDITIONS <br />1. All calis lor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2 All work shall be performr.d in accordance with this permit and wrrent Ciry of Everett Design antl Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800-424-5555. <br />��. ,��'/"or-E CG�rz:'3� ��-G�TiE� � Si.t�Ec�/Qc-�C. <br />%<',i NE'G.C'c�'sj F-Ci�.a�NS.'c�.✓ ✓c.�iic/T- <br />7 �/ � � <br />�/}� �C>t^.T/-�=— .3 c.li c'J$� <br />P.pproved �or Constr tion a1e <br />" ���G" ` _ 3- 2 1 -�S� <br />FIN 5 ECfION Date <br />Approved as Constructed <br />evc�ett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl. WA 98201 <br />Phone:259�8815 <br />� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />�"' <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />Thr, undersigned owner/applicant hereby agrees to hold and save harm� <br />less Ihe City of Everett Irom any and all claims for damages, costs, <br />expenses, or causes of action Ihat may arise because of installation <br />and mainlenance ol the improvement or olher righl�ot-way use hereto <br />applied for and lurther ac�rees to remove same upon notice Irom lhe <br />City and to re 1 ope ry damac�ed lhereby. <br />3 �' <br />, � ____-�._ � <br />Signatu e oi Applicant Date <br />WORK AUThfORIZEO BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFTER IS 70 <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />� <br />� <br />Rp <br />� <br />� <br />