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Date <br />Appllca'ior, ��r <br />PUBLIC WORKS PEFsMIT <br />Print or Type Only <br />Owner <br />Applican: <br />Describe Proposed Work <br />Project Address (il known) <br />Plan Check No: B 48473 <br />11;�p1icat.Date: OS/31/95 <br />Job Address: 4225 HOYT AVE <br />�W�er� EVERETT FAMILy <br />Tenant: <br />Yroposed Use: CLINZC <br />Deyc. of Work: <br />TI WITH ADDITION <br />SEPA <br />PRACTICE <br />Z'D <br />Pu01ic Works Permit s <br />eiev. Ueo�. + _ <br />Pu�lic Warks Fee <br />To(at Fee $ <br />�� <br />Less Apol Fee PaiE $ -�_ <br />Da�ance Due $ <br />OFFICE SET <br />��_JOB SET <br />APPROVED FOR PERMIT: DATE Z� Phone -- <br />—_/_/_ BY <br />Attach tour (4) copies ol plans lor proposed work - Draw to scale and note the (ollowing as applicable: <br />• Properly Lines <br />• Outline and dimensions of all exi�ting and <br />proposed structures on the lot <br />• Existinq and proposed utilities <br />• Centerline of streel <br />• Indicate Norih <br />• Show any proposed grading changrs <br />• Show measuremenls <br />PERMIT CONDITIONS <br />1. All calls ror inspection shall be made 24 hrs. in advance - phone 259•$$10. <br />2. All work shall be perform=d in accordance with'.his permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. 6efore you .iig. TOLI. FREE MUMBER 1-800-424-$S,ri5. <br />Construction <br />�(��� i� ��tA'��CS %�L�� rL <br />! <br />I��J��-ed <br />�,�� - <br />�'��,� ;�_ <br />Date <br />FINAL lN—ON <br />Approved as Constructed Date <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everal( WA 98201 <br />Phone: 259-8810 <br />Z <br />� <br />ACKNOWLE�GEMFNT OF CONDITIONS <br />The undersigned oH�ner/applicant hereby agrees to hold antl save harm� <br />less ihe City of Everett Irom any and all claims for damages, r.osts. <br />ezpenses, or causes of action that may arise because ol installation <br />and maintenance of the improvemenl or other righl�ol-way use he�eto <br />applied lor and further agrees lo remore same upon nolir,e from the <br />City and to replace public property damaged thereby. <br />Signature ot Applicant <br />WORK AUTHORIZEO 6Y THIS PrRMl7 MUST BE S7ARTED WITHIN <br />BE DIDLAIGENOTLY PUR UEDMTOfCOMPLEDTICN.DTH SERERM?T A1AY BE <br />CANC�V.ED BY THE CI1Y UPON ANY STOPPAGE OF WORK ON THIS <br />PROJEC7 OVER 90 DAYS GURATIOtJ. <br />