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1 Date �/ _� Public Works Permit+ � <br /> Applicalion For Bldp.DepL< <br /> PUBLIC WORKS PERMIT PubToelFee�ee $ <br /> . Less Appt Fee Peld $ --�� <br /> Print or Type Only BalanceDue S � <br /> �,�.,1 a�/� ?s1 y-oG�3 <br /> Owner//' Mailing Address City Zip Phone <br /> !7,e vl ScL���4 e y Y9 ys �/'�/1 fv¢r eT% �?' 9.�z�3 2�r'� -�/�$3 <br /> �Applicant Mailing Address City Zip Phone <br /> y // � / ' / o- � y..��II <br /> Describe Propose Work �� '' ��,7�et�� ' /�� ��'^^ ��^���r ��`^�"'�" <br /> � — �o�� U �poST s' <br /> ✓✓ <br /> W <br /> Projecl Adtlress(if known) • � � ` ' �t� � <br /> Atlach fow(4)copies of plans tor proposed work- Draw to scale and note the tollowing as applicable: � <br /> • Property Lines • Centerline of street � <br /> • Outline and dimen;ions of all existing and • Indicate North <br /> proposed structures on the lot • Sliow any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All caits for inspection shall be made 24 hrs in advance- phone 259•881 5. � <br /> 2. All work shall be performed in accordance with this permit and cu«ent City of Everett Design and Construction <br /> Slandards and Specilicationa <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> ��Nl'� S�ctill be 1r.9�cl��l°c� �,u�V-� ����,� d�q`pH,� � <br /> 1 J <br /> tOMI:/ C�.IT �O� � <br /> r ` 1 fdw. q.y.d/P� ci'F t�t'�.ce `�.o b� � <br /> f �Kr�l fR��Kti � r n <br /> � �ksJ a II e�! a �...,,. , .„,�.,,,,. o � O <br /> � x ��I� Y��-V�INa yJli,cK o t'� furb . � <br /> T <br /> � <br /> _r_ � rt <br /> C11.J� ACKNOWLEDGEME�T OF CONDITIONS <br /> M <br /> '�a�� The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less ihe Ciry of Everett trom any and all claims tor damages, costs, <br /> ��yL% �of�L� //��� expenses, or causes of action that may arise because of installation <br /> �j ; and maintenance of the improvement or other righFcl•way use hereto <br /> ,e1� applied for and further agrees to remove same upon nolice irom the <br /> A roved for Construction Date City and to replace public property damaged thereby. <br /> �i1-�� � S _.l <br /> INAL INSPECTION � �a�e "'�" y '`� �-� <br /> Approved as Constructed ignaWre of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY HIS PERMI? MUST BE STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street 6[ DILIGEIJTL'i FURSUED 1'O COMPLETION. THIS PERMIT MAY BE + <br /> Everell, VJA 98201 CANCEL .ED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 PROJECi OVER 90 DAYS DURAT!ON. <br />