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Daie=�_� .� <br />Applica!ion For <br />PUBLiG VI/ORKS PERMlT <br />Print or Type Only <br />• L-� f � I <br />Owner <br />` �. �4 =_�� f � „ � . � . r 7_ _ <br />MailingAddicss � City <br />' Put�i¢ \Yoi.s Peim�t a <br />Bldp. Deo�� � �1 .--�—L� � � �� <br />Puhhc Y/orks Fcc <br />TotelFae S — <br />L�ss �ni.l Fcc Paltl $ _ <br />ya�a�. O:i„ $_ <br />..,.-�, - r" ;' -'' 1 I <br />u �ZiP Phone . <br />i. I y <br />Zip Phone <br />Desc�ibeProposedWork /-�i :j�� ` �l�%� � ___ <br />Project Address (i( known; <br />� <br />AUach lour (4) copies of ,�lans ior pmposed work - Draw to scale and note ihe following a, applicable: <br />• PropertV Lines .• Centedine ul str=et <br />• Outline a�:a dimersions cf all existing and • Indicate North <br />proposed sUuclu« �c on the lot • Show any nroposetl grading changes <br />• Fxistiny and proposed utilities • Si„w measuremects <br />PERMIT CONDITIONS <br />1. All calls (or inspection shall be made 24 hrs. in advance - phone 2:,9-831 5. <br />2. All work shall be per�ormed in acwrdance with thi� pmmit and curren� Cily ol Everetl Design and Construction <br />Standards and 3per.ifications. <br />3. Call Localion Underground Service 48 his. before you di9. TOLL FREE NUMBER '� •$l�0•42�•555b. <br />��:��'.:-i` ...�-�t.",/= . � .%?. ' /iii�.�/ _�lu'�jL.�/q..:-iC% J _��.� / <br />—_ — --_i <br />Approve 1 for Construction Date <br />FINAL INSPEi;TiON Date <br />hpproveA a5 Ccnst�ucted <br />everett Pl,BLIC WORKF DEPARTMENT <br />� �2G0 Cedar Street <br />E•;erett. WA 98201 <br />Pl��one: 259-887 5 <br />�.';j i :� <br />ACKNOWLEDGEMFNT Uf CONDITIONS <br />� <br />� <br />r <br />V♦ <br />� <br />a <br />The undersi5r.ad owner/applicant hereby ayrees to hold a�d save harm- <br />less the City �f Everett irom any and all claims for damayes, costs, <br />expenses, or r,auses of action that may arse bccause of installa;,on <br />and mainlenance of ihe improvement or other righhof�way usc nereto <br />applied for and lurther agrees W remove same upon notice irom Ihe <br />Ci�y and to replace public property damac�ed thereby. <br />Signalure oi Applicant Datc <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />160 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DIUGENTLY PURSUED TO COMPLETION THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK UN THIS <br />PROJ[CT OVER 90 �AYS DURATION. <br />