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Date ��n`q / <br />Application For <br />PUBLIC �JVORI(S PERMlT <br />Print or Type Only <br />Mailing <br />Mailing Address <br />//U r/�t-�'\�% � <br />Zip <br />C4� <br />PubLc lVmRs Pmmrt e �� �� " <br />�iCy. Dept • <br />PuohcWorksFce 5 <br />Total Fee <br />I.essannl FcePa�d $ <br />o,�,�,:�o��,. s .UD-l'Ffi1'eG6 <br />N,�no/ne <br />�/v J%��� <br />. - . �s�_�.. ��i�.����-���.�narr�r�a � _ �_====-= <br />= �, - - - <br />Prolect Address (if knowr:) <br />Attach four (4) copies ol plans lor proposed work • nraw to scale �nd note the following as applicable: <br />• Properiy Lines <br />• Outline and dimensions ol all existing and <br />proposed strucwres on the lot <br />• Existing and proposed ulililies <br />PERMfT CONDITIONS <br />• Centerline M street <br />• Indicate Narth <br />• Show any proposed gradiog changes <br />• Showmea,urements <br />1. All calls lor inspection shall be made 24 hrs. in advance � phone 259•8$� 5. <br />2. All work shall 6e perlormed in accorAance with this permit and current City of Evcrett Design and Consiruciion <br />Standards and Specifications. <br />3. Call Lo:,�alion Underqround Service4B hrs. before you dig. T6LL FREE NUMBER 1-800•424-5555. <br />Q��rovid�, �c,,rr�«1.�5 ah ,�cL, e.,� O{-�1u„�Ps-�-er� <br />' - .�i�� ;�/o B7 <br />App�oved lor C nstrucfion � Date <br />' iiO'�'% <br />FI INSFECTION Date <br />Approved as Consiructed <br />evcrett PUBLIC WORKS DEPAFTMENT <br />� 3Z00 Cedar Sireel <br />Everett, WR 98201 <br />Phone 2��J-8815 <br />��P $ �/ia/�� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />1 � <br />� <br />Z <br />� <br />The undersiyned owner/applicaM here6y agiees to hald and save harm- <br />less the Cily of Everelt Irom any and all claims for damages, cosis, <br />expenses, or causes ol aclion that may arise because ol insfallatlon <br />and maintenance of the improvement or other righ��obway usc nereto <br />applied for and lurther agrees to remove same upo� notice I�om ihe <br />City and tu�E6Pa��OPertY da aged �hereby. <br />i � <br />// / � <br />�6+g /ur of Applicant Dale <br />WOR AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS 14SUED AND THEREf.FTER IS TO <br />BE DILIGENTLY PURSUED TO COMPL[TION. TNIS PERMIT A9AY HE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF INOFK ON THIS <br />PROJECT OVER ?0 DAYS DUFiATIGN. <br />