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Date.�!� �-� � <br />� Application For <br />PUE3LiC \IVORKS P�RMIT <br />Print ur Type Only <br />Owner <br />Describe Proposed Work <br />7fi <br />Project Address (if known) <br />5�13�Z3.�� <br />Mai{ing Address <br />ng Address <br />l. %i�.O i�l <br />� <br />a�mi�wotl.sPo,mn< G�J��•3�f5 <br />B'aB� Oep�. x <br />Pu�llc Ylorks Fee 5 <br />Tolal Foa <br />Less Appl Fee Paid S <br />Balance Uoe <br />S zo =� <br />/3 <br />yyzo3 ?� s'ilrs o <br />� Phone <br />C9J <br />`ttach fo�r (4) copies of plans for proGosed work - Draw to scale and nota Ihe tollowing as applicable: <br />• Property Lines • Centerline of slreet <br />• Outline and dimensions of all existing and • Indicat.� Norlh <br />proposed structures on thP lot • Show any proposed grading changes <br />v Existing and proposed utilities Y Show measurements <br />PERMIT CONDITIONS <br />1, ,ii calls tor inspeclion shall he made 24 hrs. in advance - phone 259-8$'• 5. <br />2. .411 work shall be pericrmed in accordance with this permil and current City of Fveretl Design and Construction <br />Standards an.�, Specifications. <br />3. Call Location Underground Servi�e 48 hrs. before you dig. TOLL FREE NUMBER 1�800-424-5555. <br />� �.�u� �way ������,�,< �:ATE�.a� i.trJ SiTF. <br />for <br />Approved as <br />e�-aretr <br />� <br />��. <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phon�: 259-8815 <br />/ Date <br />�-�-yb <br />Da�e <br />ACKNOWLEDGEMENT CF CONDITIONS <br />� <br />O <br />� <br />Yr <br />0 <br />� <br />The undersigned ownedappiicant hereby agrees �o holC and save harm- <br />less the Cily of Evere�t from any and all claims for d�mages, costs, <br />expenses, or causas of ac�ion that may ari:e because oi installation <br />and maintenance of the improvement or olher right-of-way use hereto <br />applied for and fyrth � g,rees �o remove same upon notice irom the <br />City and �o repl Ee � Pw� Iy damaged thereby. <br />i � <br />� j / ,� � /S/ <br />� <br />.� <br />Signatur of pplica Date <br />WOFK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THERF.IFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPL[TION. THIS rLRMIT MAY BE <br />CANCELLFD BYTHE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />