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� � Public Warks Permi�a <br /> Date <br /> Bltlg.Uept.t_��— <br /> Application For __ <br /> PUBILIC WORKS PERMIT PUDTOIIFeaFee $ _ <br /> Less AppL Fce PaiE 5. <br /> BalauceDuo S <br /> Print or Type Only <br /> —�—�7-�"' �5�� �f6� av L``-U�-�s..�l �/�' Zc'�a' 3�.z ' �D7 � <br /> Mailing Aodress City Zip Phone <br /> ( " .C� ' o � bsl �N�..i:_�" `i�YZ�6 �7s-�`''-7a7o <br /> Applicant Mailing Address �ity Zip Phone <br /> Describe Proposed Work �'�-"""` l �I'Y ','? ` /µ�V ,�t <br /> _. W <br /> Prolect Address(if known) �'s�/ �� / ' � + ,�r � <br /> � <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 ol all existing and • Indicate North <br /> proposed slructures on thn,lot • Show any proposed 9rading changes <br /> • Existing and proposed utilities • Show measuremr.nis � <br /> ■ �� DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS � <br /> 1. All calls for inspection shall be made 24 hrs. in 2dvance- ph�ne 259-881 5. <br /> 2. All work shall be perlormed in accordance wilh this permit and current Ciry of Everelt Design and Construction <br /> Standa�ds and Specificalions. � <br /> 3. Call Localion Underground Service 48 hrs. before you dig.TOLL FREE NUM R 1-800•a24•�555. <br /> o r�5 � e o <br /> I � b��G � �e � �h I— <br /> � � � � � � <br /> �° � (���� � <br /> gc,� � a, �� a <br /> � �� <br /> ACI(NOWLEDGEMENT OF CONDITIONS <br /> The undersigned 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 aclion that may arise because o� inslallation <br /> and maintenance oF ihe improvement or other right-of-way use herelo <br /> applied for and further agrees to remove same upon notice from the <br /> Aporoved for Cunsiruction Da�e pity and to replace puhlic properry damaged thereby. <br /> FINAL INSPEC:TION Date Date <br /> Approved as Consiructed Signature of Applicant <br /> WORK AUTHORIZED BY THIS PERId�T MUST BE STARTED WITHIN <br /> everelt PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUBD AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B�_' <br /> Everett,WA 98201 CANCELLED BY THE CRY UPON ANY STOPPAGE OF WORK ON TH1S <br /> Phone: 259�8815 pROJEC"OVEF 90 DAYS DURATION. <br /> I <br /> I <br />