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` ' _.,� i. <br /> � i r..r <br /> Date�� PuCli<Worka Permil• � <br /> •.��. <br /> Application For 61tlp.Dept• r 7 � � <br /> PUBLIC WfJRKS PERMIT P°°Ta,eFeaFBe s <br /> Lass APpL Fea Paid S <br /> Balance Due S <br /> Print or Type Only <br /> C iu;� t�A�J \' 1��PN.J �d� c�+�.t.g.c�,nl� C,x o�' 9��5� �5��-39i.s' <br /> Owner Mailing Address City Zip Phone <br /> ��� Mai�ing Address Ciry Zip Phone <br /> Applicant <br /> Describe Proposed Work ��(X� � '� � � <br /> Q,ce� � cP.tt:�-e.�1 <br /> W , <br /> Prolect Address(if known) ��� ' � <br /> Attech four(4) copies of plans for proposed work• Draw to scate and note the following as applicable: � <br /> • Property lines • Centerline of street � <br /> • Outline and dimensions of ell existing and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities � Show measurements � <br /> DO NOT N�RITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All cells lor inspection shall be made 24 hrs. in advance• phone 259•881 5. � <br /> 2. All work shall be performed in accordence with this permil and current City of Everelt Design and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 4B hrs.belore you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> �e�.»�'r O <br /> �J�f kr �Y <br /> ���b��� � <br /> N� �Q1 u��t N <br /> �,,z���/,...-� � <br /> 3..,�-f� a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everett from any and all claims for damages, costs, <br /> expenses, or causes of action that may arise because of instailation <br /> and maintenance of the improvement or other righFof-way use hereto <br /> applied for and turther agrees to remove same upon notice Irom the <br /> Approved for Construction Date City and to replace pub�ic property damaged thereby. <br /> FINAL INSPECTION �01e Date <br /> Approved as Constructed Signature of Applicant <br /> � WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WiTHIN <br /> everett PUBLIC WORKS DEPARTMENT 1g0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA�J8201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259•8875 PROJECT OVER 90 DAYS DURATION. <br />�I <br />