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�. <br />_ _ :>.;:r::�.::E.�,. <br />Date �� 8� <br />Application For � <br />PfUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />Describe Proposed Work <br />City <br />?�ojectAddress(ifknown) .>/L`J�[�i G"L�L��(/ /t/f/�(i � <br />AL•ach four (4) copies ot pl�ns (or proposed work • Draw to scale and note the following as <br />• Property Lines � <br />• Outline and dimensions of a�l existing and <br />propoeed structures on the bt <br />• Existing and proposed utilities � <br />PERMI7 CONDITIONS <br />Publie Worka Permit s �� _ �O� <br />Blap. Dept ♦ <br />Public Worka Foe <br />Total Fee $ <br />Lesa AppL Fae Paitl � <br />dainnte Due a _Z3�— <br />Zip <br />• Centerline of street <br />• Indicate North <br />O Show any proposed grading changes <br />• Show measurements <br />7. All calls for inspection shall be made 24 hrs. in advance - phone 259•f381 5. <br />2. All work shall be performed in acwrdance with this permit and current City of Everett Design and Construction <br />Standariis and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424-5555. <br />�! <br />. <br />.� <br />�d� To BE Oa.✓E ,vE,e �qo�,,��c� <br />PGq,v vy.-Fo 6-as- 86 � c- /� ¢- c-s. <br />SiTE GiPy,a/NG J�G A�� <br />ST�cETS A.eE Ta BE ,�E�T CGE/J.e OF <br />.Gi.2 Tr Ei C. .<f.u.L� S//9LG 8E CLE'A.cJCA <br />U/' AS pi,PFC rE0 .�� Tilc �CiBG /G <br />G!idl.'.�'s I.dS�-�EGTOIZ . <br />L_ Z/L � % /.� �To <br />Approved foi Cor,st tion Date <br />FlNAL INSP[CTION Date <br />ApUroved as Constructed <br />everett PUBUC WORKS OEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 759-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />LJ <br />Tha undersigned owner/applicant hereby agrees to hold and save harm- <br />less ihe City of Everett f�om any snd all claims tor damages, costs, <br />expenses, or causes of action that may a�is2 because of inslallation <br />and maintenance oF the improvement or other right-ol-way use hereto <br />a�ie nd�rtheAr agre�{qg���e��i�pR�srom;�p�. <br />Cl�v and to-feo c 4n,Clia.,ar.�naliv rinm�..oa e�.e.,.�... <br />Si�nature oi App1ic t �'--� ate <br />WC�RK AUTHORIZ BY THIS PERMIT MUST BE STARTED WITHI�J <br />180 DAYS OF DA PERMIT IS ISSUED ANJ THEREAFTER IS TO <br />P� DILIGENTLY PURSUED TO COMPLEI'ION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />