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Date� Public Workg Pe�mil� _ J ��� <br /> l! � <br /> Application For B�dg.�co�.• <br /> PUBLIC WORKS PERMIT PUoto�aFoeFee � _ <br /> LQ59 AppL PCO POid $ <br /> ��/) n <br /> BBIBlICB�t10 � �"� (.<� <br /> Print or Type Only <br /> ���„ �,,.� , �5�0�/��}.,��.� ��,�- lc�� � s.� - a 5.��3 <br /> Owne� Mailing Address City Z�p Phone <br /> �� �c.�-, l��e. 3a3 s� ..� � <br /> qP� � i ng Address c.it i Zip Phone � <br /> c� <br /> ��/ m <br /> Describe ProUosed Work � `�='� �.1 / � <br /> .. �+ <br /> -�I 'T7 <br /> a+ --1 <br /> N 2 <br /> _ W = � <br /> mo <br /> L- /,-- � c� <br /> Project Address pf known) _ ✓ �`= L G CyQ LEE ~ o m <br /> Attach tour(4)copies ot plans for proposed work• Draw to scale and note the following as applicable: � _� <br /> • Properly Lines • Centerline ol s;reet � m <br /> • Outline and dimensions of all existing and • Indicate North Q z <br /> proposed structures on the lot • Show any n�oposed grading changes D -� <br /> • Existing and proposed utilities • Show measuremenis � r s <br /> —I N <br /> 1 <br /> DO NOT WRITE BELOW THIS LINE O o � <br /> PERMIT CONDITIONS � 3 <br /> 1. All calls for inspection shall be made 24 hrs. in advance-phone 259-881 5. � i m <br /> 2. All work shall be pertormed in accortlaace with this permit and current City ol Everett Design and Construction �^N <br /> Standerds and Specifications. <br /> 3. Call �ocalion Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> m�' <br /> O z c� <br /> -i r <br /> m <br /> a <br /> A <br /> � � <br /> 2 <br /> a <br /> � z <br /> -� <br /> x <br /> O � <br /> � <br /> z <br /> a � <br /> � <br /> � <br /> m <br /> l�' <br /> � � ACKNOWLEDGEMENT OF CONDITIONS <br /> � The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the Ciry of Everett from any and all claims for damac�es, costs, <br /> � expenses, or c2uses of aclion thal may arise because of installation <br /> _//• / � � / � and mainlenance of the improvement or olher righl-ohway use hereto <br /> G�� l ✓1"' 7 � ap ied tor and further agrees to remove same upon notice irom the <br /> Approved for C no s�lion / Date Cit and to eplace public property damaged Ihereby. <br /> �— �� ��/6�rf� ' ,/ <br /> EIM INSPECTION Date <br /> Approved as Constructed Sip6ature ot Ap IicaM Date <br /> WORK AUTHORIZED THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE P RMIT �S ISSUED AND THERFAFTER IS TO <br /> � 3200 Cedar ulreet BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259�8815 PROJECT OVER 90 DAYS DURATION. <br />