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Date /��F / <br />Appiication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />l.4/ra,5� 1�I G 185�45 <br />Mailing Address City <br />Mailing Address City <br />ZIp <br />Z�P <br />Pu01it Works Parmit • ��— ��� . <br />BIdQ. Depl. • <br />Pu011c Works Feo S <br />Total FBa <br />Leas ApP� Foe Peitl S <br />O <br />9alanceDue S 2oQ- <br />Describe Proposed Work / �,� / �� C LJ/ �� ���/ /�C�G.�Y� <br />Pro�ect Address (if known) _ .�0�2 — LL'J!/E.�.-' ...5'%/ <br />Attach tour (4) copias of plens for proposed work - Draw to scaie and note the Iollowing as appiicable: <br />• Property Lines <br />• Oul�ine and dimensions of all existing and <br />proposed stroctures on the lot <br />• Existing and proposed utilities <br />• Centerline ot streat <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PEqMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrs in advance • piione 259•881 5. <br />2. All work shall be peAormed in accordance with this permit end current City of Everett Desiyn and Construction <br />St�ndards and Specificationa <br />3. Call �ocation Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />� �EtPCATE �.2iUEtJAf/ CU,F'd G'i/T Ta /�h'TCN /�coT <br />�CA�✓- <br />S�i,� t�,t'ivE�✓Aj/ To BE Co�✓SrRiit7�� PEP �iTf/ STA�/O.��D <br />a,�o7. <br />c�.c� d� ��E�� T dE �'E��,o ✓Ev Pc�2 J�cT�o�✓ 3 j.7 <br />bf' rNE �'iTj� aF E✓E.eEi7 L�ESrG.t/ SYqN.�A�eDS, <br />i / <br />� .��.� <br />Approved as Constructed <br />everett PUBLIC N/ORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />'he undersigned owne�/applicant he�eby agre5s to hold and save harm- <br />less the City uf Everett from any and all claims (or demeges, costs, <br />expenses, or causes of ection that may arise because of Installatio� <br />26/8 7 and maintenance of the improvement or other right�ol-way use hereto <br />applied for and fuAher agrees to remove sama upon notice from the <br />Date City and to repla public property amaged thereby. <br />� �J o� �m c � �-'f. �-- �% l J�,S� i <br />Signature of Applicant Date <br />WORK AUTHORIZED 6Y THIS PERMIT MUST BE STARTED WITHIN <br />180 DAY5 OF DATE PERMIT IS ISSUED AND THEflEAFT'cR IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLE� BY THE CITY UPON ANY STOPPAGE OF WORK ON TH�S <br />PROJECT OVER 90 DAYS DURATION. <br />