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0 <br />��� <br />�H,�C�n <br />Hx� <br />rC C� <br />H �1 <br />�ii �"1 �ii <br />y H <br />zp <br />H <br />OH� <br />H�g <br />Q1r (i <br />t��� <br />HH <br />y <br />C�C� <br />C+1 � [�1 <br />ZHm <br />H O V� <br />I�v <br />Date <br />��91 � � <br />qpplication For <br />PUBLIC WORKS PERiVIiT <br />Print or Type Only <br />' IpuEl¢ \Pode Porm/�l� • <br />Blag. Dept • `f�� <br />Pub�icWo�katea $ <br />To�alfeo <br />Les� PpO� Feo Pab $ <br />BalancoDuv S <br />' � `r � Cit ZiP Phone <br />Owner Mailing Address 1' <br />Descrihe Proposed Wark <br />Projed Address (il knOwn) <br />Allach four(4) copies of plans for proposed work- Dmw to scale and note� CQ°�fedine o( �PeC1� able: <br />• Properry Lines • Indicete North <br />• Outline and dimensions ot all ezisting and � Show any p�oPosed grading c5anges <br />proposed structures on ihe lot • Show measurements <br />• Ezisting and proPosed ulilities <br />PERMITCONDITIONS <br />i. All calls tor inspec�ion shall be made 24 hrs. in advance- phone 259•8810. <br />2. All work shall be performed in accordance with this permit and currenl City of Everett Design and Construclion <br />Standards and Specilicalions. <br />3. Call Lor,alion Underground Service 4B hrs. before you dig. TOLL FREE NUMBER 1-800•424-5555. <br />}�6� ���.�. /��,�-� ��,��-. <br />�� <br />5_cct 9/ <br />qpproved for Construction Date <br />FINAL INSPEG710N Date <br />�pproved as Constructed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cetlar Streel <br />Everetl, W!� 98201 <br />Phone: 259�6870 <br />Z <br />O <br />H <br />� <br />O <br />a <br />ACKNOWLEDGEMENT OF CON�ITIONS <br />The undersigned owner/applicant hereby a9rees to hold and save harm� <br />less the Ciry of Everelt Irom any ar,d all claims for damages, cosis. <br />expenses, or causes of aclion lhat may arise because of installalion <br />and maintenance ol the improvemeN or oUier right-o4way use herelo <br />applied for and Wrther agrees to remove same upon notice Irom ihe <br />Ciry and to replace public pwperry damaged ihereby. <br />SignaWre ol APPlicant Date <br />80RDA STOF DATE PERMIT ISEISSUED ANDBTHEREAFTER IS TIO <br />BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF W�RK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />