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4ate�: /�jrC <br />�% �cs�,.� `��L�/9l kJ/ris-,��,//]� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Applicant <br />� � ��s �� <br />Mailing Address <br />/ j�F�/ 5torz <br />Mailing Address <br />�%%a �4kp <br />Pupl¢ Ylorks Permii a /��«/ O / <br />Biag. Dept. a <br />vu�hc Worxs Fec <br />Tolal Fec S <br />Le55 Appl Fee Paia S <br />Balance0ue $ .�SDO <br />�Lr�,. �t'%--� � c Ol��o Y/ .�zBSq <br />Z�P Phone -� • <br />E rl�esf �/ 00 <br />City <br />Phone � 7��� 7n <br />D/escribe Proposed Work "�� � LNc� � �{/P�„/ � � nZ �%JP �pp � �p �L� � �i4�1/C <br />-tn �. �. .�. .;.. i ... -. . i ' _ _ _ r <br />�+ �n„-� _t- � .f�-'ic,,s f,- <br />Project Address (if known) �3 � <br />" s <br />w, <br />W <br />Attach four (4) copies of plans for proposed work - Draw to scale antl note the following as applicable: � <br />�� <br />• Property Lines • Centerline of street � <br />• Outline and dimensions of all existing �nd • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE � <br />PERMIT CONDITIONS O <br />t. All calis for inspection shall be made 24 hrs. in advance - phone 259-8810. � <br />2. All work shall be performed in accordance with this permit and current Ciry or Everelt Design and Construclion <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. be(ore you dig. TOLL FREE NUMBER 1-800•424•5555. � <br />/, (.�a�,� 71a �Je �n� ��- P�c .-, �� �odec� oh /2/O-y0 4 <br />��/ f�e. �!/�'�it G�Jr,P,Es ,C7,�:�/, �f,� Gf�acleo�/ <br />/ � <br />),�._��-g� V� <br />O <br />a <br />�D <br />Approved <br />FINALlNSPECTION �� `✓ `�— <br />Approved as Constructed <br />everett PUBLICWORKSDEPARTMENT <br />� 3200 Cedar Stroet <br />Everett, WA 98201 <br />Phone:259�8810 <br />ACKNOWLEUGEMLNT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the Ciry of Everelt from any and all claims tor dama�es, costs. <br />expenses, or causes of action ihat may arise because of installation <br />and m i �enance of ihe improvement or o�her right-of-way use hereto <br />applie or and furlher a�rees to remove same upon notice irom the <br />Cily a d to replace pu6lic property dar�ged thereby. <br />� /-- ,o '� /Z/�-�� <br />Si ny�ture ol Applicant / Dale <br />9iiK AUTHURIZED BY THJS PERMIT MUST BE STAHTED WITHIN <br />180 DAYS OF DATE PERi�11T IS ISSUED AND THEREAFTER IS TO <br />13E DILIGENTLY PURSUED TO COMPLETION. THIS PERMI! MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />