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Date <br />�� <br />Appiicatlon For� <br />PUBLIC WORKS PERMIT <br />arint or Type Only <br />+-- . J l I ', <br />i �i�T,y.L. /�'��� r � i rz� � � � <br />Owner Maiting Address <br />� � ,:, , E-�.� i�r: . ��,���_: ti�if_ <br />Applicant Mailing Address <br />Describe Proposed Work <br />��t- l � l l�r )�—�—� h i r f'��'.(11 ; 4 <br />_ �.w <�.-,.� ..�...,e.... <br />��1 Publ!c Worke Permit r __._ <br />aiaf.. oeo� + <br />PoblicWorksFee $ <br />Tolel Fee <br />Less Appl. Fae Paia $ <br />Balanco Duo S <br />�.. I,G�/l' -1 7�� ' <br />CitY Zip <br />- ,� -�d� -7c: �� <br />" - C ' ` " �' - <br />� �,. C `'��_ �:_' ,t-3.:,F.�7 //,ii..�� `�/.. <br />Project Address (il known) � � T� <br />Attach four (4) copies of plans for propoaed work - Draw to scale and note the followin�3 as applicabl�:� <br />• Property Lines • G.nterlinr, of sireel <br />• Outline 2nd dimensions of all existing and • InAicato Nortn <br />proposed structures on �he lot • 3how any U�uposeA g;uJics changes <br />• Existing and proposed utilities � V Show measuremants <br />PERMIT CONDITIONS <br />t. All calls for inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in accordance with ihis permit end current City ot Everetl Uesion and Construction <br />StandarcJs and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dic�. TOLL FREE NUMBER 1•800•424-5555. <br />.%�l� �J'%' U � l u� <,<;s ,,-:�. , »�% ,t' �. "�a U�,c'��,0 y'�� E3� <br />�?�;;.,. � <br />Approved for Consiruction Date <br />FINAL INSPECTION Date <br />i Approved as Conslructed <br />�� everett PUBLIC VJORKS DEPARTMENT <br />3200 Cedar Street <br />�i � Everett, WA 98201 <br />Phone: 259-88 7 5 <br />W <br />F- <br />Yiw <br />��!' ! <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEMENT UF CONDII'IONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City or Everetl irom any and all clain�s for damages, cosls, <br />expenses, or causes of aclion Iliat may arise because of installation <br />and maintenance of the improvement or other right-of�way use hereto <br />applied tor and Furiher agrees to remove sarne upon notir.e irom ihe <br />City and to replace public properry damaqed there6y. <br />Signature of Appli�ant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST dE STARTED WITHIN <br />780 DAYS OF DATE PEFMIT IS ISSUED AND THERFAFTER IS TO <br />BE DIUGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WO!iK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />