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Date_� 7 <br />Application For <br />PUBLIC WORN:S PERMIT <br />Print or Type Only <br />L{�r,ln, Sl,a�m�,K 3�_, <br />Owner Mailin9 <br />Applicanl <br />Describe Proposed Work <br />citv z�u <br />�✓riC �f� <br />r � 18 Z0,3 <br />City Zip <br />ProlectAddress(ifknown) ����� f�-�-,1-���Q- <br />Attach lour (4) copies of plans lor proposed work • Craw to scale and note ihe iollowing as applicaGle: <br />• Prnperty Lines <br />• Outline and dimension. of all ex;sting and <br />propased siructures en ihe lot <br />• Existing and proposed utiliti?s <br />PERMIT CONDITIONS <br />Publ¢ Works Permll s �� ��� <br />BICg. Dept. s ���5 <br />a�er�wo�xsFao g <br />Sotal Fee <br />Less AO�� Fee Paia $ � <br />Beiance Oue 5 Z� GG <br />P Centerline oi stieei <br />• Indicate Nor;h � <br />i Show any proposcG gradin9 chan aes <br />• Show nieasurements <br />Phoe <br />All calls for inspection shall be made 24 hrs. in adr�r,ce - phone 259-881 5. <br />All wor4e shall be perlormed in accordance with this permit tnd current Ciry ot Everett Design and Conslrudion <br />Standards and Specilications. <br />Call location Underground Service 48 hrs. before you dip. TOLL FREE NUMBER 1•8�Q•424•5555. <br />.� <br />.� � �� �c �1== Z �J't " ii % <br />Approved tor Constr � (� - ate <br />� � � ` <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cf�dar Street <br />Fverett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONOITIONS <br />� '. <br />� I <br />� � <br />I <br />Zi� <br />O'� <br />H <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the City ol Everetl from +nv and all claims �or damages. co;ts, <br />expenses, or causes of action that �.iay 3rise because ol installation <br />anA maintenance ol the improvement or other right�of-way use iiereto <br />applied tcr end furiher aqrees to remove same upon noiice Irom ihe <br />City and to replace public pr perty damaged tliereby. <br />� � i <br />� (;i' �l` :�'//�S <br />Signature ol Applica� Date <br />WOqK AUTHORIZ��L� BY THIS PERMIT MUST BE STARTED WITH�N <br />1&0 DAYS OF DATE PERMIT IS ISSUEO ANC THEREAFTEP IS TO <br />BE DILIGENT�" PURSU�U TO COMPLETIOIJ. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOP.�AGE OF WORK ON THIS <br />PROJ[CT OVER 90 DAYS DURATIOM. <br />