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Dat� �� <br />Application For <br />PUBLiC WORK� <br />Print or Type Only <br />�, <br />�� <br />Mailing A <br />,��u�, C� � jr ��� ���.. �. _"i_o" ` i <br />� <br />� <br />M <br />�ERMIT <br />O <br />O <br />� O O <br />�y o 0 <br />� <br />� w� <br />P�oM1c Wo�Fs Permn • ✓ �' ��� <br />BIa9 DCPL • <br />VuUbcWorkaFee S <br />TotaiFee <br />Le55 ApP�- Fpe Pai� S� <br />Baiance0ue S ��� <br />2ip Phone <br />� oa= <br />?� o aoc� <br />� �^'� <br />Applicant Mailing Address City Zip Phone <br />DescribeProposedWo�k��✓�izf �'�L�1 w/ �5�� C_.�.�lhS�¢-% <br />Project Address (il known) <br />,C <br />Attach four (4) copies of plans for proposed work - Draw to scale and note tne lollowing as applicable� <br />• Property Lines <br />• Outline and dimensions ot all existing and <br />proposed strucWres on the lot <br />• Existing and proposed utilities <br />• Centerline ot streel <br />• Indicate North <br />• Show any proposed grading ch3nges <br />• Show measurements <br />1'ERMIT CONDITIONS <br />7. All calis for inspeciion shall be made 24 hrs. in advance- phone 259•8810. <br />2. All work shall be pedormed in accordance wi�h ihis permit and wrren� Ciry of Everett Desi�n and Construclion <br />Standards and Speci!ications. <br />3. Call Lccation Underground Service 48 hrs. betore you dig. TOLL FREE NUMBER 1-800•424-5555. <br />�/��.�GCa'�.Cc.> ,�y/uvr�i�/Q"I�� �"_ <br />/ <br />l.�o� vu�i .�w 32 :�y.=c�vtiG <br />y. <br />for <br />Approved as Consiruc�ed " <br />evere[t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phane:259�8810 <br />� /, j� <br />f.�f�i3�-'OX 8 c:.f.�.S� <br />�L � � OF <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />�w <br />� / <br />O <br />a <br />The undersigned ownedapplicanl hereby a9rees to hold and save harm- <br />less the City of Everett from any and all claims for drmages, costs, <br />ezpenses, or causes of action that may arise because ol installation <br />and maintenance ol th� improvemerA or other riyht-of�way use hereto <br />applied tor and luriher agrees to remove same upon nutice Irom Ihe <br />City and lo rqplace,publir. properry damaged Ihereby. <br />re <br />Date <br />WORK AUTfiORIZED BY TI11S PERMIT MUST BE STAI7TED WITHIN <br />180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />B'c DILIGENTLY PURSUEU TO COMPLEI'ION. THIS PERMIT MAY BE <br />CA�CELLED BY THE CITY UPON ANY STOFPAGF OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATICN. <br />