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Date�� <br />App�ication For <br />PUBLIC Vb'ORKS PERlVIIT <br />Print or Type Only <br />PUDICWOrkSPo�m:ia/ �%l�J J� <br />GI�19. DePI. � �Lj �" �� <br />PuM1hc wo�kiFee � <br />,o„� F�e s _ <br />Less Rnul Fee Paitl g_ — <br />2 G�<p <br />o,i,��� o�� S _ <br />pan Colemnn /Od ) Lo.�n6ninl E✓.^iP fi� �cFza / ZS�`'��1S _ <br />O�.vner Mailing Address City Zip Phone <br />Mailmg Address <br />Ci�y Zip Phone <br />Descnbe Proposed Work �'1 A(,�1 .CIJ1L11��j"1 � ll.,.—rP i'/ (��1�/]� l� <br />�l J <br />Project Addres5;d knownl <br />Attach four (4) copies M plans lor proposr.d work � Draw to scale and no!e ihc toiloe+ing 2s apUlicahle: <br />r Propeity Lines <br />• Outline and Aimensions of all exishng and <br />propo5ed Slructure5 on Ih� lot <br />• Existiny and proposed utnrties <br />• Centerline ol siree! <br />• Indicate Ivorth <br />• Show any proposed gradin9 changes <br />• Show measuremems <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-8810. <br />2. All work shall be performed in acr,ordance wi(h ihis permit and current Ci�y of Everelt Design and Construction <br />StanAards and Specifications. <br />3. Cail Location Ucderground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424-5555. <br />-1JrA� 4�� `k�� I I- l 9-� <br />Approvetl for Consiruc�ien Date <br />�G,�=�� /o -�' Su <br />FINAL WSPECTION Dala <br />Apprrn•etl as ConstruCted <br />everetl PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Slreet <br />�veretC WA 98201 <br />Phone:'59�flE110 <br />ACKNOWLEDGENFP�T OF CONDITIONS <br />� <br />� <br />The undersiqned owner/applicant hereby a9ree5 to hold and sa�;e harm- <br />less ihe City ol Everetl Irom any and all claims tor tlamage,. r,osts. <br />expenses, or causes of action that may arise because ol installation <br />and maintenance oi the improvement or uther righbof-way use hereto <br />applied �or and lurlhnr a9rees tc remove same upon notice from ihe <br />City and to replace public p�o�rry darnaged Ihereby. <br />�� <br />/� � <br />(/ � -s �j�7 <br />91gr lure o` �pplicant Date <br />WORK AUTHORIZED BY THIS PERMIT Iv1UST BE STARTED WIT�HIN <br />180 DAYS OF DATE PERMIf IS ISSUED AND THEREAFTER IS TO <br />BE DILIGEIlTLY PUFSUED TO COMPLETION. THiS PERMIT MF.V BE <br />CANCELLEJ BY THE CITY UPON ANY STJPPAGF OF WORK ON THi9 <br />PROJECT GVER 90 DAYS DURATION. <br />