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Date ��D <br />Application For <br />,PUBLIC \NORKS PERMIT9�zRig3 <br />' j�y P�STING_--- <br />a��rt nr Tvoe Only <br />v�m�� wo�ks ae�� •/`�� ��! <br />em9. oeot • --�'--�i- <br />Public Works ie5 $ -__ <br />Tatal Fee <br />Less AO��� Fee PaiE g '� <br />a ��--- <br />eaianoeoue _ <br />Applicant <br />Describe Proposed Work <br />— 14 <br />Prolect Address lif known) <br />�.. u w nnn i.ra A./�' <br />Allach four (q copies ot plans tor proposed work - Draw to scale and nole the following as applicable: <br />• ProPertY �ines <br />i Outline and dimensions of all existina and <br />proposed structures on the lol <br />• Exis�ing and proposed utili[ies <br />• Centerhne of street <br />• Indirate North <br />• Show any proposed 9rading chan9es <br />• Show measuremenis <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hre. in advance • phone 259•681 . <br />2. All work shall be pe-formed in accordance with lhis permit and current City of Everelt Design and Construclion <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-500•424•555 . <br />� .�v�b-e c�m� p�� �'� E �G�����'�' <br />� ��n� ? Lv <br />�� _ ,,y�� /y� %�Uf�Ccrr l,lv�/= � � <br />f�.< � L�-f .c�� �C Pa.�, a <br />� • Gl'cc'�'oa" ' p��c��.v �SUO -� <br />�,�-,a�� �a� � � <br />6, n/� 02�r�wL o-� � �,�� �,�� a cCc'� � <br />� tu� Cd'"`°"�-,.t.el% o� _ / " _ �o cv <br />d,,, c%Po�-f c�cl�i� �'� L'G�� �O �r, <br />�'i�� �• �a��e�� �''' <br />�� Lef. .����- <br />S�f�t i.-.��f - �.��� <br />d.c,�.u= �I �'�"' �vozi i� '�'�'�'"/�C <br />qpproved as Gonstruccea <br />everett PUBLIG WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8810 <br />Date <br />/�-'�-i 3 <br />W <br />� <br />�w <br />_/ <br />� <br />V <br />ACKNOWLEDGEMENT OF CON�ITIONS <br />The undersigned owner/applicant here6y agrees lo hold and save harm� <br />less the Ciry ol Everett iroin any and all claims for damages, costs, <br />expenses, or causes of acti�n that may arise �ecause of installalion <br />and maintenance of the imProvement or other righl-of-way use herelo <br />ypplied for and turiher agrees lo remove same upon notice from the <br />City and lo replace public A Pe'ty damaged thereby. <br />� ' ' Date <br />Signa ure of A cant <br />WORK AUTH IZED BY IS PERMIT MUST BE STARTED WITHIN <br />180 DAYS O OATE PERMIT IS ISSUED AND T'iEREAFTER IS TO <br />BE DILIGENTLY PURSUE-D TO COMPLETION. T�il� PERMIT MAY B[ <br />PROJECT OVER �0 DAYS DURAT ON. STOPPAGE OF WORK ON THIS <br />