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3 <br /> Date ��'% � PUC�cWorFSPerm/il�• � �� �- <br /> eiao oea� •=L�- Z��— <br /> Application For <br /> PUBLIC WORKS PERMIT Pu��¢\YOMSFeC <br /> ra�.,���� s <br /> �ass nooi Fcc aa�o S <br /> H eaiance o�c S <br /> [��a� Print or Type Only <br /> k��lx <br /> Q f-'. <br /> ra' �`� HRti'/31oN As50G /940/ 40TH�✓b k/%G�0 Lt�NNGJdOG` g803�v 527-ZO$S <br /> y � Owner Mailing Address City Lp Phone <br /> FC Ci <br /> H:� /' <br /> '��] H'{1 UL1J��1•� <br /> U.H Applicani Mailin9 AAdress Gity Zip Phone <br /> y r <br /> � z <br /> y Cy Descrihe Proposed Work �� ���� ��� " ���� 'F�-R���'��0�� <br /> O H <br /> � �g - <br /> �� � <br /> ay� W <br /> r H y ��t� � Ev�,e� ,-r MA�� In�RY �r-r—�� f� ---- �..� <br /> �y y Prolect Atldress(if known) <br /> O H � <br /> 7 t1(A Attach lour In� r.opies of plans lor proposed work- Draw to scale and note ihe lollowing as applicable: <br /> � �[� • Property Lines • Centerline of street � <br /> C+7 • Oulline and dimensions of all ezisting and • Indicate North <br /> yp� proposed siructures on�he lot • Show any proposed gra0ing chanyes <br /> • Ezisting and proposed u�ilities • Show measuremeNs � <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERMIT CONDITIONS <br /> � 7.All calls for inspeclion shall be made 24 hrs.in advance�phone 259•8810. � <br /> 2.All work shall be pedormed in accordance with this permit and current Ciry of Everett Design and Construction <br /> �.� Standards and Speciiications. <br /> � � 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. �) <br /> G <br /> � � � <br /> Iv� /� / n y/- //A /� / <br /> ' f ; ✓��[,G, �i✓GIL/_=' / �l L1wvC /'iC�/��Y''li''-'"� <br /> '/�;-:1'�"�f�-- 1�' <br /> � �_� �-��-�d (� <br /> '����0 0 <br /> ' � <br /> � � �CKNOWLEDGEMENTOFCONDI;IONS <br /> The undersigned owner/applicaN hereby a9rees�o hold anci save harm� <br /> ' less the City o' Evere�� from any and all claims for da�na9es. cosis. <br /> +�t! expenses, or causes ot aclion Ihal may arise because ol installation <br /> and mainlenanre of the improvement or other n9hPol-way usc here�o <br /> applied for ano further agrees lo remove same uP�n notico from Ihe <br /> � � Approved for Construction ���� Gity end to rep�ace public property damagetl ihareUy. <br /> FINAL INSPECTION Date — Dale <br /> Approved as Constructed Signa�ure of Ap91!cant <br /> WORK AUTh���RIZGD 3Y TNIS PERMIT MUST BE STARTED WITHI�! <br /> everett PUBLICWORKSDEPAfiT�dENT 180 CAYS C� DfTE P�RMIT IS ISSUED AND THEFEAFTER IS TO <br /> � 3200CedarS'reel BE DII.IGE�TLV �I:G:E":c0 TO COMPLETION. THIS PERMIT A1AV BE <br /> Everrlt WA9H2O1 CANCELLED BV THt GITY UPON ANY STOPPAGE OF WORK ON THiS <br /> Phona:259-8870 pf70JECT OV[R 90 DAYS DUF7�TION. <br />