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Date �" P�o�,�wo,hsa�,m�i. <br /> ��:.r eioo ocn� . l`/, � /�l � <br /> 17 <br /> Application For � —'-�-�1— <br /> PUBLIC WORK� PER��IIT PublicWonaFec <br /> To�e��ea S <br /> LessAOV-FenPaiO $ <br /> Print or Type Only Ba�a�=.o�� s <br /> �fdlil �,1 �P7����t/�r'1� /.�G� l�n/,It <br /> Owner Mailing Atldr s City 2ip Phone <br /> � �Q�VkJ-i <br /> Applicant Mailing Address City Zip Phone <br /> A � i <br /> G U�;,� � �� �-vi �n si�•�alt f ,. . � ;.�. - ( <br /> Describe Proposed Work _ , <br /> � <br /> Prolect Address(il known) I�7��'��LqJ� � <br /> Attach lour(4)copies of plans lor proposetl work- Draw to scale and note ihe tollowing as apClicable: � <br /> • Property Lines • Centerline ol street /A <br /> • Outline and dimensions of all existing and • Indicate North V� <br /> proposed strudures on the lot • Show any proposed grading chan;;es <br /> • Exisling and proposed utilities • Show measuremenis Y <br /> f� <br /> �O NOT WRITE BELOW THIS LINE <br /> PERMIT CONUITIONS � <br /> 1. All calls for inspection shall be made 24 hrs. in �dvance- phone 259•88S 5. � <br /> 2. All work shall te performed in accerdance with Ihis permit and current City ol Everett Design and Construction <br /> Sfandards and Specilications <br /> 3. Call Location UnCerc�round Service 48 hrs. before you dig TOLL FREE NUMBE9 1-800•424•F555. � <br /> O <br /> �l/Bl/C Gvo,c�;�S ���:�T .;2��7 ;��o�,�o � <br /> �i2-96 I_ <br /> ,�� O <br /> a <br /> ACKNOWLEDUEMENT OF CONOIl10NS <br /> The undersigned owner/applicant hereby agrees to hold and save ha�m� <br /> � less thc Ciry of Everett Irom any and all claims for damages. costs. <br /> expenses, or causes ot action ihat may arise because ol installation <br /> and mainlenance ot lhe improvemen� or other right-obway use hereto <br /> applied lor and (urther agre�; to remove same upon notice irom ihe <br /> Appwved lor Conslruction Date City and lo replace public�.voperty damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Construcled SignaPve of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHOH12ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Slreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WF 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PEFMIT MAY BE <br /> Phone: 259�8815 CANCELLtD BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />