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� �z) j � <br /> I-1 I_ n Puolm wmxs Peemn y�� ` <br /> Date�1—�l� eiaa o�oi.• ' <br /> qpplication For <br /> PubLc N'o�h1�eB <br /> PUBUC WORKS PERMIT T����F=� s <br /> �ev Aooi Fee vam $ <br /> Balance 0urt S �`, l_ <br /> �� '�'� Print or Type Only <br /> C � � C „ <br /> _ � ^ r'� � 7�� _ ;7 <br /> C.�y Zip Phone <br /> � �r O ncr ailing Atldres5 <br /> � <br /> !� L <br /> ��� CitY 2iP Phone <br /> Applicant Mailing Address <br /> �A l /� <br /> � �escrihoProposedWo�k _ r � ^ ����� ��1�\ 'C�� 1 <br /> ��� _ <br /> p� W <br /> � y � <br /> ��� � 1� � � `��t— <br /> �y Proiect Address lil knownl � <br /> �� Altach four(4)cop�es ol plans�o�Propos�d wo�k� Draw to scale and�ote Ihe lollowin9 as appllcable: � <br /> • Centedine ol streel <br /> • Property Lines � Intlicate Norlh <br /> �t+ • Oulline and dimensions ol all eaisting and � Show any pwposed 9raAing changes <br /> iAproposed strucW res on Ihe loi � Show measuremeNs M <br /> W • Ezisting and proposed utilities W <br /> DO NOT W RI'E BELO�'�'THIS LINE O <br /> � PERMIT CONDITIONS � <br /> 1.All calls for in5peclion shnll be made 24 hrs.in advance-phone 259•8810. <br /> 1 2.All work shatl be peAormed in accordance with t�is permit and current Ciry of Everett Dosign and Construction <br /> i �� ' StenderdsandSDecilications. � <br /> 3.Call Lxation Undergmund Servica 4d hrs.belore you dig.TOLL FREE NUMBER 1-800'424•5 . <br /> � A. APP��cntirr �.,��nL�. ��c�c,eqac � i rx�:c-�.��YL �c: �" rR�N �tc.,st O <br /> ' �� �Z` N1Q�fJ . • <br /> . I � . �i'S�� �c n�t' � �.I n�� i N=�I�LI. N� M�-1"E�c_U �IRT�Z_ S�l�-V�C_�=- I... <br /> r <br /> � <br /> �' ''' a <br /> � �L�_i <br /> � ACKNOWLEDGcMENT OF CONOITIONS <br /> �1� (l�� 7he undersi9ned owner/applica�T hereby agrees lo hold and save harm� <br /> � less the Ciry of Everett I�om any and all claims lor damages, cosls. <br /> expenses. or :auses ol aclion thal may arise because of installaUon <br /> � - � � �/I � � � 7,� � and maintenance ol ihe improvement oi olher righl•o�•way use hereto <br /> �I applied for and further a9�ees to remove same upon notice irom the <br /> qpproved lor Consir � <br /> Da e City a�d lo replace public p�aPe�ry damaged Ihereby. <br /> ��� z Z r-� 1� �-�- /r�S� <br /> Date Date � <br /> FINAL INSPECTION � • Signalure ol ApPlican <br /> p p p r oved as Conslrucled W O R K A U T H O R I Z E D BY THIS PERMIT MUST BE STARTED W�THIN <br /> �w�everett PUBLICWORKSDEPARTMENT 180 DAYS OF DAT[ PERMIT IS ISSUED AND 7HE R E A F 7 E R I S T O <br /> 3200 Ceder Street BE DILIGENTLY PURSUED 70 COMPLETION.THIS PERMIT MAY BE <br /> UEvere�t,WA 98201 CANCELLED BY TNE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURATION. <br />