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f> � Pu01it Wotks Pormn a �! l_-/L <br /> Date � <br /> � 7U l�� c'�._S eme.oe��.•— i <br /> Appiication For <br /> PUBL.IC Vi/ORKS PERMIT PublicWorksFee <br /> Ta�al Fee S���?� <br /> LessROP�-FeePa10 S /' <br /> Baiancc0ue $ /V� <br /> Print or Type Only <br /> ��'l -y3�t�- <br /> —�'������� i�,� `/5l s l-�0 Si= :S,'�%ai,rr��/L ��t//� ��'d9'/� <br /> Owner Mailing Atldress Ciry Zip Phone <br /> I-�r,rifi�sfFl ����� SGuti'�- - <br /> �ant Maihng Address City Zip Phone <br /> DesGribe Proposed Work �i � '' � "� ° — � / ��I � � <br /> / ` � ��� — <br /> _ le�Y�i <br /> Projecl Address(if known) <br /> ZS�3 'F{O\��� ��t= ! <br /> AUach four(4) copies of Plans lor proposed work- Draw to sr,ale and note the lollowing as applicable: � <br /> • Property Lines • Centedine of street � <br /> • Outline and dimensions of all existing and • Indicate Norlh <br /> proposed strucWres on ihe lot • Show any proposed greding changes <br /> • Existing and prcposed utitities • 56ow measurements � <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERM17IT CONDITIONS <br /> t.All calls for inspection shall be made 2��hrs.in advance-phone 259•8810. � <br /> 2.All work shall be performed in accordance with ihis permit and wrrent Cily of EvereQ Design and Constmction <br /> Standards and SpeciticaLons. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•80J•424•5555. � <br /> � � � � / <br /> �� � .Q� C J�d G'-'-la �',C.�Y�S CiL/i``c'�� �O 7_ -:�D <br /> /� ! � <br /> �BA <br /> . �/ <br /> � <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> 7he undersigned owner/applicant hereby agrees to hold and save harm- <br /> — less the City of Everetl from any and all claims for damages, costs, <br /> expenses, or causes of action that may arise because of installalion <br /> � � �� � � and maintenance of lhe improvement or olher righ��of-way use hereto <br /> ��-:�- � 7 applied for and further agrees to remove same upon notice irom the <br /> Ap oved or Co rucli / ate Cily and to replace pubiic property dam thereby. <br /> ��jG— /_��^ �� l ��5 Ci <br /> FINAL INSPECTION Dale �'�� <br /> Approved as Construded Signa ure ol A Iicanl Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHI�J <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PEFlMIT IS ISSUC-D AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BC <br /> EveretC WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phona 259�8810 PROJECT OV[R EO DAYS DURATION. <br />