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yk� x <br /> r'" 0 r <br /> T Y.. <br /> Date 5 +` " Public Works Permit* e"-` <br /> , _ Bldg.Dept.* ' <br /> Application For <br /> PUBLIC WORKS PERMIT Public <br /> cWortal ks Fee $ <br /> Less Appl.Fee Paid $ <br /> Print or Type Only % Balance Due $ r�P> ©a <br /> , . p w q 1005 - 0116 - <br /> tt.)r7,:it' _d,--uni <br /> -, t--?-) 160xi- ,z26/5 aso 5 ,... --43,--.. M. <br /> Owner Mailing Address City Zip Phone <br /> Applicant Mailing Address City Zip Phone <br /> le <br /> Describe Proposed Work l <br /> i)f�/;. < .� <br /> W <br /> Project Address(if known) IA O D MA D2-c. JeN .>. . Elm <br /> .Attach four(4) copies of plans for proposed work- Draw to scale and note the following as applicable: <br /> • Property Lines • Centerline of street <br /> • Outline and dimensions of all existing and • Indicate North C11) <br /> .,W... proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements ,,' <br /> Ca <br /> k,4t DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259-8810. <br /> ;,'2.All;work shall be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800-424-5555. <br /> 4 j, 1 ? 4 i k Oni.v lam` 1' cter,� 2 <br /> Ilmim <br /> . 7iialczA46--- Ce)-t-a-6F-et-t,ec Toni V 4ivie)et-citee('a-ce.„ e,-, ZgrOzti <br /> • <br /> a t' off'` 4ii ( as Q' O <br /> 7a, .......,.. <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm-, <br /> less the City of Everett from any and all claims for damages, costs, <br /> ..,f expenses, or causes of action that may arise because of installation <br /> —/ey— and maintenance of the improvement or other right-of-way use hereto <br /> applied for and further agrees to remove same upon notice from the <br /> ,. A 'oved or nstr non Date City and to replace public •roperty damaged thereby. <br /> .+R <br /> FINAL INSPECTION Date arMgiM► .. r" 4e: - <br /> Approved a Constructed Slgna ure of Aagr'cant '" Date <br /> /, \ WORK AUTH•-IZED BY'ir IS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS I DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> l Phone:259-8810 . PROJECT OVER 90`DAYS DURATION. <br />