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r <br />Date_�1L�g� <br />/ Application For <br />PUBLIC Vi/O�KS PERMaIT <br />�rint or Type Only <br />Mailing <br />Describe Proposed Work _ <br />ary <iN <br />Project Address (il known) �"� `� o �����`"`-"'^/�—`���� aG <br />Attach tour (�7) copies of Flans lor proposed work - Draw lo scale and note the tollnwing applicable: <br />o Property Lines <br />• putl�ne and dimensions of all existing and <br />pwposed struclures on the bt <br />A Existing and proposed utilities <br />Pu0 m Ylorks Pe�mit a__ <br />Bldg. Depl. a �� / /� <br />Pu�bcWo�ksFeo S <br />toRd Fw <br />Less PpGI Fee Paid $ <br />Baiance D.m � <br />• Centarline of street <br />• Indicate North <br />• Show any proposed grading c''�an,es <br />A Show me25urements <br />os����� ���� <br />DO NOT WRIT[ BELOW THIS LINE <br />PERMIT CONGITIOKS <br />1. All calls br inspection shall be m2de 24 hr_. in advance - phone ?59•881 5. <br />2. All work shall be pert�rmed in accordance with �his permil and c�.irtent City of Evere�t Design and Constr�clion <br />S�andar�is and Specifica�ions. <br />3. Call Location Undergro�nd Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800-�}24•5555. <br />� /�G.�iCG��/'� Pe'����T /��E�G�i,eF-:U <br />for ConStruttion <br />Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar St�eet <br />Everett. WA 98201 <br />Phone: 259-8815 <br />AGKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />� <br />� <br />The undersigned ovrner/applicant hereby agrees to huid and save harm- <br />less the City ot Everet� from any and all claims for damages, costs, <br />expenses, or causes ol action lhat may arise because ol installa!icn <br />and maintenance of the improvement or other righ4of-way use hereto <br />applied for and `urther agrees to remove same upon notice hom the <br />City and lo replace public properry damaged ihereby. <br />Signature ot ApPlicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUSi BE STFFTED V�'ITHIN <br />180 DAYS OF DATE PERM1IIT IS ISSUED AN7 TNEREAPTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY TH[ CITY UPON ANY STOPPAGE OF WORK ON THIS <br />FFOJECT OVER 90 DAYS DUHATION. <br />z <br />0 <br />� <br />c� <br />m <br />-i �7 <br />... --I <br />N 2 <br />0 <br />m <br />co <br />mo <br />� m <br />_ -�-I <br />f�7 <br />oz <br />a -a <br />rx <br />.� .. <br />—� N <br />< <br />'�1 <br />o tv <br />TI 1� <br />3 <br />--i m <br />m� <br />N <br />or <br />c� m <br />c cn <br />3 � <br />z c'� <br />—1 r <br />. �, <br />D <br />A <br />�--I <br />S <br />b <br />Z <br />--� <br />� <br />N <br />O <br />1 <br />C') <br />m <br />