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Datell=L_V__J� Poblic Worka Poy'rm�lt♦ <br /> ApplicationFor BItlB�Dept�. y �f0��' <br /> PUBLIC WORKS F�ERMIT PublicWorksFeo <br /> Tote1 Fee s . <br /> LessApO�FeePaiE 5 <br /> Balan<e0un $ <br /> ?rint or Type Only <br /> —j�%,l�i�r,.� t'I,v��A�� �7 CA57" f'(Nyr,,,l,� T�c�,�e%i 9 �.�e�� <br /> Owner Mailing Address City Zip Phone <br /> s�w,e � <br /> Applicaot Mailing Address Ciry Zip Phone H <br /> DescribeProposedWork ✓�u ��c� A/E�.� �-a���J� - ys? /S,e�sii`rG /�iciti�'� � <br /> � H H <br /> H '+f <br /> '-i �-] <br /> Prolect Address(if knawn) � � [i <br /> Attach iour(4)copies of plans for proposed work- Draw to scale and note the tollowing as applicable: � � <br /> • Propedy Lines • Centerline of street �^ � <br /> • Oulline and dimensions o!all exis�ing and • Intlicate North /� <br /> proposed strucW res on ihe lo� • Show any proposed grading changes � <br /> • Existing and proposed utili:ies • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE C zy <br /> PERMITCONDITIONS o y N <br /> 1. Atl calls for inspe�tion shall be made 24 hrs. in advance-phone 259•881 5. K <br /> 2. All work shall bc performed in accordance with this permit an�current City of Eve�att Design and Construction � O � <br /> Standards and Specifications <br /> 3. Call Location Undergiaund Service 40 nrs. betore you dig.TOLL FREE NUMBER 1-800•424-5555. � � <br /> �p� � N <br /> /(/� ��l,��/G /l�O��s f �-��/I�1/T � � <br /> ���lJ"if��J- - � • � <br /> C?��� � <br /> �,�/�=� p � <br /> � � . <br /> � <br /> � <br /> H <br /> ACKNOWLEDGEMENT vF CONDITIQNS � <br /> The undersigned owner/applicant h2reby agrees to hold and aave harm- <br /> less the City ol Everett from any and all clains for damayes, costs, <br /> - expenses, or causes of action ihal may arise Gecause of installation <br /> and maintenance ol the improvement or Mher righFol-way use hereto <br /> applied for and furiher agrees to remove same upon nolice trom the <br /> Approved for Consiruction Date City and tu replzce public properry damaged ihereby. <br /> FINAL INSPECTION Dale <br /> Approved as Construcled Signature of ApplicaN Date <br /> everete PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WI�HIN <br /> O 3200CedarS�reet 180 JAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98207 8(' DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAV BE <br /> Phone:259-887 5 �ANCELLED BY THE CITY UFON ANY STOPPAGE OF WCRK ON THIS <br /> I PROJECT OVEF 90 L�AYS DURAT!ON. <br />