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Date��� � <br /> r�m�_cloa� vcrmn a / ' r' p <br /> Apnliwlion For ei�� oeu�.+_8��2�=�i <br /> / <br /> PUBLiC WORKS PE�3Ml�' PubilcWoiknFee <br /> ,o�a�Foe s <br /> �essnooi.Fee Paitl $ <br /> Print or Type Only o,���.�o�d s_ <br /> Lc�J�(��e l�1 l�� 9 Kn.�s��� C—✓e.e� �i✓� 9�'�03 �s3-64o� <br /> Ownei Mailing Address City / Zip Phone <br /> _ �Onr(� l !)af )7� ��/Z�'r NF k� �l` ��N / 1,�� �I[�_/ cf�A—�1.� ! <br /> Applicant Mailing Address City Zip Phonr. <br /> Describe Proposed Work ��/�Ll A.� _ CiQ/�QG '� <br /> i—� i <br /> Project Address(it known) ____�'�� k p�`(Iy_` --- � <br /> Attach four(4)copies of plans lor oropcar.d work - Draw to scale and noie ihe lollowing as applicab�e: � <br /> a Property Lines • Centerline o�street � � <br /> • Outline and dimensr.��of all exis;ing and • Indicate North <br /> proposed siructur=5 on the lot • Show any pro�osed grading changes <br /> O Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BEI.OW THIS LIIJE <br /> PERMIT CONDITIONS � <br /> 1. All calls tor inspection ahall be made 24 hrs. in advance- phone 259•881 5. � <br /> 2. All work shall be performed in accordance with ihis permii a•�d r.urrent City of Everett Design and Construction <br /> Standards and Specifi.ations. <br /> 3. Call Location Unoergrcund 'oervice 48 hrs. belore you dig. TOLL FREE NUMBER 1•$00-424•5555. � <br /> � <br /> �w <br /> _/ , <br /> � <br /> a , <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> i <br /> The underslgned owneqapplicant hereby agrees to hold and s;3vc narm� ' <br /> –� less the City of Everett from any and all claims for damages, costs, ,� <br /> expensea cr causes of action that may arise because of in;tallation 1 <br /> and maint�nanr,e of the improvement or other righbof-way use hereto <br /> Approved lor Consiruction Date �P��lied �or and furini�r aqrers to removc same upon notice 'wm the <br /> Q�y anA to�eplace publlc proporry dama9eA �iierr,by. <br /> FINAL INBPF_CTION Date <br /> Appruved us Conslructed Signaturc of Applicant Datr <br /> evere� PUBLIC WORKS DEPARTMENT WORK AUTHORIZED �`( THIS PERMIT MUST BE STAR7ED WITHIN <br /> � 3200CedarSlreet 180 DAYS OF DATE PERMIT IS ISSUED AND TNEREAFTER IS TO <br /> Eve�etL WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone: 25°�8I31E CANCELLED BY TH[CITY UPON ANY STOPPAGE GF WURK ON THIS <br /> PRWECT OVER 9G OAYS DURATION. <br />