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. �i�Y� <br /> . � Y <br /> l�-I 3-G7C� <br /> � � <br /> Date— a�oi��we,k.ro,m�i. � _ _ <br /> Application For eiaa�neo�.• <br /> M1 <br /> pIJBLIC WORKS PERMIT "' - <br /> P"eticworksFen S <br /> Tutal Fee <br /> lesc Apol Fee Paitl $— <br /> �.uanca Due ��� <br /> Print or Type Only <br /> �QQt 1 ��I Z 11 �i�1`� o�-'`Y��' SG�% `��`�''� G`-�'�X.L <br /> Owner :�SailingAtldress Cdy Z.� Phone <br /> _ 98���� ����g� <br /> i,pplicanl Mailing Address Ciry Zip Phone <br /> Uescribz Proposed Work �-�� � ��— ���I u � ' 'M�� - - <br /> yy j�' � <br /> Projec�Address(if known) Q� ( I� � � ^ — - - � <br /> Attach fr,ur(4) copies of plans for proposed work- Draw to scale and nole lhe following as applicable: w <br /> M Property Lines • Centerline of streel ♦^ <br /> O Outline and dimensions of all existing and • Indicate North �/� <br /> propoc=_d siructures on ihe lot O Show any proposed gradi�g changes <br /> • Existirg and proposed utilities • Si•�ow measurements �/� <br /> �� DO NOT WRITE EiELr1W 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 peiformed in accordance with this permil and current City of Everelt Design and Construction <br /> Standards and Specifications. <br /> 3.Cali Loca�ion Underground Service 48 hrs.before you dio TOLL FREE NUMBER 1-80Q•424•5555. � <br /> \/ <br /> � � Y�U� �LA��US 'C�'t�"ED I a-S'�I � <br /> �� � <br /> � <br /> i <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicanl hereby agrees to hold and save harm- <br /> less ihe Cily of Everett from any and all claims br damages, cssts. <br /> expenses, or causes ol action that may arise because of ins�silation <br /> and maintenance ot the improvement or other nght-of�wav �se i,ereto <br /> applied for and further agrees to remove same upon nctice Irom the <br /> A r e " Co irucl� �a�e Ciry and lo replace public properly damaged thereby. <br /> � .�, � D �.7 �v � i� �i <br /> FfNAL NS �E T �N ` Date � F ~ �z'_�� <br /> Acproved as Cons�ructed ign r ot Applicant Date <br /> WORK AUTHORI2ED BY THIS PERMIT MUST BE START�D WIT�HIN <br /> everett PUBLIr,yy0RK5DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED ANC THEREAFTER IS TO <br /> � 320�CedorSVeet BE DILIGENTLY PURSUED TO COMPIETIODi.THIS PERMIT AIAY BE <br /> Everett,WA 9P201 CANCELLED 6Y THE CRY UPON ANY STOPF'AGE OF WORK�JN THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURATION. <br />