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Date 8 /� �/� <br />i <br />Application For <br />PUBLIC WORK� PERMIT <br />Print or Type Only <br />Address <br />mamng naoress <br />�� <br />/..5� �)ec �.eoD 1= <br />Describe Proposed Work i�t�� I� �� 10 n� • Utive r�� �..��� <br />Project Address (if known) <br />Publm Warks Pormlt • 86 — 33 � <br />BIOg. 0«pl. • <br />Publie Works Fee S <br />Totel Fec <br />Lesa Appl Fee Pe�d S <br />BelenCaD�e S �QOO <br />2 03 `1S �/-3S 63 <br />Phone <br />c���G 3��s � 3770 <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all exisling and • Indicate Norih <br />proposed structuros on the lot • Sh�•x any proposed grading changes <br />• Existing and proposed utilities � • Show measurements <br />PERMIT CONDITIONS <br />Phone <br />7. 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 of Everett Design and Construction <br />Standards and SpecificaUons. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />T- �U.ClSTf_' (lCT �LJEcJ D�/N�ccJf.�� i .tli �A.✓CF f�E.� <br />��%�/ S%AtiDA.eO <br />�yi7��i/r:� � <br />�•�'7 a.v0 f'.�,_ cEcr,n.✓ ,� 3. 7 <br />�� �.% ,%�7�� <br />Approve� -C ruc�ion / � Date <br />���..�r�� /�-�� <br />FINA SPECTION Da�e <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 982C 1 <br />Phone: 259�8815 <br />ACKNOWLEDGEMENT OF CO ��DI710NS <br />W <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicanl hereby agrees to hold and save harm- <br />less the City of Everett (rom any and all claims tor tlamages, costs, <br />ezpenses, or causes of action that may ause because of installation <br />and maintenance of the improvement or other right-obway use hereto <br />aFPlied (or aod lurther agrees lo remove same upon notice Irom the <br />City and to replace public property damaged Uiereby. <br />n4�u��-w,. � / s" . % 9 SSW <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STAPTED N'ITHIN <br />180 DAYS Of DATE PERMiT IS ISSUED AND THEREAFTER �S TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON ANY STOf-PAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS �URATION. <br />