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Date��S 6 8l -• 2(�Z <br /> PUEIie Works Parmil• / <br /> Application For emc.oeoc• <br /> PUBLIC WORKS PERMIT PuJIICWorksFee <br /> Totel Fea s <br /> Les�ApO�fae PeiE S � <br /> eei,��ao�� S -��� <br /> Print or Type Only <br /> �o(�er� �, k�e %� 7c:�o -`��� /avr. S�, Sno�iom,'s�i QSZ.90 SGB -G-f9''/ <br /> Owner Mailing Address C!!y Zip Phone <br /> -Su m e _ <br /> Applicant Mailin,q Addres:� City Zip Phone <br /> Describe Proposed/Work EX C a V 4 �e 7o_r Pro posed �i4 s e m e vIf_ p�p� c oH s �✓'� �� <br /> _ �"n-rrated /e_ ml�qnKmed� a(or�a nor7� an� Wcs7� � i�e o � �.et /S <br /> CY`CSTv�oncl • �^e r�fad �n vo%�me l�ln o � i'�p�s�� ti <br /> ,/ '1 / �' / / '�� <br /> —CO�v1r�v �/udi �.^�S ./`i !G : 45 Shuv�n c�w aacom � ' s s W <br /> ProlectAddres:lifknown) �of �S C�'�5/—wor�d � �LYs �Q � � <br /> �l0/6' <br /> Attach four(4)copies of plans for proposed work• Draw to scale and note the followiny as applicable: � <br /> � Property Lines • Centerline ol street � <br /> • Outline and dimensions of all existing and � indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> �O NOT WRITE BELOW THIS LINE � <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be mad�e 24 hrs. in advance-phone 259•881 5. � <br /> 2. All work shall be pertormed in accordance with Ihis permit and current City ol Everetl Design and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 hrs befora you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> f� `t� wo�t- r�Us; aE- .do,✓� so /�s .u�r ro O <br /> ..Zl��fJCT Ti/E SG.�•C'OUNDi.✓rj LoiS: <br /> S .�tir /l/�'c�Ersy�ef/ ��io�r/ A�vO SEdii»ENT9TiortJ � <br /> CoN%POL /.S To •BE �c?�E' HS l�i:e'EtTEQ �f/ i./c�' � <br /> CiTf/ c�' E✓E.eE7T P�BeiC ltib.e.rs _Ti..U'�'Fti'8.e. O <br /> �, �j�f',eov�'iC o�' TNiS �E�.r��r F� EXC'Ari/�Tiv�/ DOES' � <br /> ND% /r/ECE'sS�s�yCy AP�.eOdEO Ti�E S'��" PCA�/ ../S <br /> s�e.�.rrE.o. <br /> � ACKNOWLEDGEMENT OF CONDITIONS <br /> The widersigned owner/applicant hereby agrees to hold and save harm• <br /> ;,� ��,��y,p,,,,,.;",d less the City of Everelt from any and all claims for damages, costs, <br /> ���� �/�6 expenses, or causes ot action that ma/ ariso because ol installation <br /> and maintenanco of the improvement or other righhol-way use hereto <br /> applied for and furiher agrees to remove same upon notice trom Ihe <br /> Approved for ConSir �ion �_ Ci�y and lo repl pu I' proper�y ag ereby. <br /> ���� � � '��� �.� n�K 1 �l; ��s� <br /> �- �✓ri l -1-U d �) a `� S 6 <br /> FINAL�INSPECTION � Dale <br /> Approved as Constructed Signature of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE :�TARTED WITFIIN <br /> � 3200CedarSireet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everetl,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMI7 MAY BE <br /> Phone: 259�8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WCRK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />