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Date' // y yo <br />Application For <br />i'UBLiC WORKS P'ERNIIT <br />Prinl or Type Only <br />Pu�Lc 1vmFs Ppimit • � �' Jv." <br />a�a� o��� , 90 /3 U c-9 � <br />Pubi.c Works iee <br />Total Fee $ <br />LessAopi. Fee Paia 5 __ _ <br />ea�r��..o�e S ��. <br />��,� � c y C�-.v; r. ��� �/�iD s�c.r��� fve y� 1 � i � r.�- � Yro <br />Ow���_. Malfing Address Ciry Zip Phone <br />�-�4'rc.� <br />qpplicant Mailing Address City Zip Phone <br />Sr.ribe PropoSed N'ork <br />Project Address (if known) -�.� � % �/ G �T � S � <br />3 ZNv ST <br />Attach four (41 copies of plans for proposed wo�k - Draw to scale and note Ihe following as applicable�. <br />• Property Lines <br />11 Outline and dimensions of 311 existing antl <br />proposetl structures on Ihe lot <br />• Exisling and proposed utilities <br />• Cenierline ot sireet <br />• Indicate North <br />• Show any proposed grading ch,anges <br />• Show measuremen�s <br />+ t <br />PERMIT CONDITIONS <br />i. All calls for inspection shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be peAormed in accordance with this permit and current City ol Everetl Des c(�f✓ai��dnst�hiQu.rY� �OOAN2364 <br />Standards and Specilicalions. � <br />3. Call location Underground Service 48 hrs. befere you dig. 70LL FREE NUMBER 1-800•�`f7���5j . <br />ELDG 9b39.5� <br />E SRCH 44.50 <br />�F.VW�' ��0.00 <br />CHECK 8664.00 <br />1"4�� i'��� �Li¢J., C� — Z7-90 <br />Approved lor Conssr on Date <br />���--- <br />��- � -ir - L_ <br />FINAL INSPECTION Date <br />Approved as Consiruc!ed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Ce:2r Sir�et <br />Everett. WA 98207 <br />Phone: 2"3�8810 <br />ACIiNOV1LEUGEMENT OF CONDITIONS <br />Z <br />� <br />Thc unticrs�gned owner/applicant herebyagrees to hold antl save harm- <br />less Ihe Cdy of Fveretl irom any and all claims tor dzmages. costs. <br />ezpenses. or causes ol action Ihal may arise hecause of installatlon <br />and mainlenance ol Ihe improvement or other right-ol�way use nerelo <br />applied �or and lurther agrees to remove same upon notice hom the <br />City and to �eplace public property damaged thereby. <br />�-w-��.�,��_ - - <br />Signature ol Applicant Date <br />WORK AUTHOR12ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF OATE PERMIT IS ISSUED AND THEREFFTER IS TO <br />BE DILIGENTLY FURSUED TO COMPLETION. THIS PERMIT MAY BC <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJ[CT OVEh P,�, DAl'S DUflATION. <br />