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p��: <br />. : y .' � t `�� ry _. . <br />� StPa> � „ <br />� � ; �GN . <br />Date � B 8S <br />ApPlication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�'� c lt u--Js� � a�D i� l' S r�G/ u y e�t / <br />Cwner Mailing Address <br />�-- �I�a.., i c -f( /K S i�U cv�'i,��-�+� <br />Applicant M1failing Address <br />Describe Proposed Work �d ✓ r�� A / •71-ta � <br />'vT <br />FO.E f'.ViC�%N.: Ch�!/2C <br />ProjectAddress�ifknown) � /!/a�.tovl. ,G7`" <br />Public Works Permii s O� G�� <br />BItlB� Oeo�. • <br />Pu01ic Worka Fee <br />Tolel Fee $ <br />Less Appl. F=e Peid 5 <br />BalancoDve $ �7S%J <br />� <br />Zip <br />E-X � 5 Ti.VCr <br />Attach four (4) cupies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Properly Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicale North <br />proposed �tructures on the lot • Show any proUosed grading changes <br />• Existing and proposed utilities • Show measurements <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be perfor.^;,J In accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Loca�ion Underground Service 4B hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />5� P�o��a� A 5��d�06 STiziO OF LAti�Sca�iyG <br />/iGONG �JA.OiSON .C�!/�G; <br />S, P�1vi.ri(r ,.SydGG 6'E A H�i..viin:�ir, of 2"o,�' CGess <br />i � .i <br />f�' AS�HGLT PLACEt� D/i�.�' y��of Ci�USi/[=/� <br />SU,C��,aciit/(r %Gi/� CGGtpSE: <br />Approved as <br />everett <br />� <br />Date <br />PUBLIC WORKS DEPARTM1IENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259�8815 <br />G <br />W <br />� <br />� <br />� <br />� <br />O <br />■ <br />Y/ <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersi9ned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett irom any and all claims for damages, costs, <br />expenses, or causes of action that may arise because ol installdtion <br />and maintenance of ihe improvement or other righl�ef-way use hereto <br />applied for and further agrees to remove same upon notice irom ihe <br />Ciry and to replace public property damaged lhereby. <br />�-��.� <br />ig e ure of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILiGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS UURATION. <br />r��. , " .. � " .-. ..... <br />H H <br />H �_] <br />Hy <br />N � <br />[yT] <br />O � <br />� <br />�H <br />z <br />�y H <br />K � <br />n � <br />� H <br />� <br />� <br />� <br />. � <br />� <br />� <br />� <br />a <br />� <br />