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� <br />a- y-� � <br />�.. <br />Date_— <br />� ��Application For <br />PU�3LIC WORKS PERMIT <br />O <br />O <br />Print or Type On� � �'�. � �p � gp �' � �' g � <br />.��i N�w N IfJ � O lt� .�-� M N ' � <br />� M w �O M �O � .Y M �O <br />W M W bT W <br />�.�. i�,.��,�, [�j��. i?�, �a �>r�� L�,,,, <br />• vc�. <br />33 �.n� � <br />Applicant <br />oNSot�n <br />�5.�.��m <br />Address <br />City <br />O O O O <br />000,-y <br />M O 117 t� <br />� W M � <br />M <br />/ <br />Pu�1¢ WoiAe Permit � �`� _ / <br />a�d9 �>.� . _a9- zz �.jo <br />Pu�Lc WOiks f'ee <br />Tolel Fee S <br />Less AOPI. Fee PeiU $ <br />BalanceDue $ � ``� <br />.- <br />Phone <br />.�3 ,S� - D f��S� <br />2ip Phone <br />Describe Proposed Work � "�v `-' �-�� ' Lo-� / -�%� °SP . L�� �z ' � �(���n6' Q'[/L« <br />� <br />Prol�rct Address �il kno�.cnl <br />s3 js- �� a <br />Attach four (4) copies of plans tor proposed work - Draw to scale and note the lollowing as applicable: <br />• Properry Lines • Centerline of streel <br />• Outline aod dimensions of all existing and • Indicate Nor�h <br />proposed structures on the lot • Show any p�oposed grading chanyes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259•8810. <br />2. All work shall be performed in accordance wilh this permit and cu«ent City ol Everett Design and Construclion <br />Standards and Specifications. <br />3. Call Location Undergruund Service 48 hrs. before you dig. TOLL FREE NUMBER 1-$00•424•5555. <br />�;����• /. �a <br />Approved for Constru io Date <br />,��1��� /-� - `� <br />FINAL INSPECTION Date <br />Approvod as Constructed <br />evere[t PUBLIC WORI:S �Ef`ARTM[NT <br />� 3200 Cetlar Street <br />Everett, WA 98201 <br />l'hone: 259•8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersic�ned owner/applicanl hereby agrees to hold and save harm� <br />less ihe City of Eve�ett Irom any and all claims lor damages. costs, <br />exponses, or causes ol action that may arise because ol installalion <br />and maintenanCe ol ihe improvemert or other right-of-way use herelo <br />applied for and luriher agrees to remove same unon notice irom Ihe <br />Cily and to replace UubGc propertv damaged thereby. <br />Signature ol Applicant Date <br />WORK AUTHORIZ[D BY THIS PERMIT MUST BE STP.RTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER �S TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPGN ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATIOIJ. <br />