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/ _ . <br /> .�� <br /> � y ^ ' �� Pu01iC WO�kS�Blmi�ar,' � p.� <br /> �atE N emooeot• z/-� �(0�.— <br /> Application For <br /> PUBLIC WORKS PERMIT Publ¢WorxsPee <br /> Tmaliee $ <br /> Le5sAp01.Fee Paia S — <br /> 0alance Due � <br /> Print ar Type Only <br /> ."� L .. �' ' ri�i�f t � ��n ��� FI/f /�� 7a �� � <br /> Owner <br /> MaiHng Acldress Gity Zip Phone <br /> �_�0���7�'ra�r� �veret� cl���� r�s� - �f�� S <br /> qpplicant <br /> Mailing Address CiP� Zip Phone <br /> � n n c lYsi�,7 � ]/'A .p /T i ✓7 (�.�l=�-l�E� N�/'P ' /p i! <br /> Describe Proposed Work _ l <br /> — W <br /> Proiect Address(il known) �--'-+-'-'�_�'� � <br /> � <br /> Atlach lour(4)copies of plans for proposed work- Draw to scale and note ihe following as aFlPlicable: � <br /> • Properry Lines . • Centerline of streel <br /> • Oulline and dimensions of all exisling and • Indicate North <br /> proposed struclures on ihe lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremenis M <br /> W <br /> DG NOT WRITE BELOW THIS LWE O <br /> PERMIT CONDITIONS � <br /> 1.All calls for inspection shall 6e made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be peAormed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specifications. � <br /> 3.Call Location Underc�round Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. <br /> ' LIiJ-E.c6. �C1��.�Lt. �i%:,j-,.,c� /��df ��-E'�-C�`L1.CQ' O <br /> � �L��ylcK��"�"' � <br /> a -y -`�/ (!� <br /> O <br /> a <br /> ACKNOWLEDGEMENT O� CONDITIONS <br /> The undereic�ned owneUapplicant hereby agrees to hold and save harm- <br /> less the Cily o1 Everett Irom any and all claims lor damages. cosis. <br /> ezpenses. or causes of action that may arise because of installation <br /> and maintenance of the improvr.ment or other righbobway usa here�o <br /> applied for and turthei agrees to remove same upon notice trom the <br /> l.puroved 1or Consuuction �d�e City and to replace Uublic property damac�ed ihereby. <br /> �iNAL INSPECTION Date Date <br /> ,?pproved as Conslructed <br /> Signature of ApPlicant <br /> INORK AUTHURIZED BY THIS PERMIT MUST BE STARTED WITHI <br /> �,�,i.���� PUBLICWORKSDEPARTMENT 1g0 DAYS OF DATE PERMIT IS ISSUED AN� THEREAFTER IS TO <br /> �� 3200CedarSireet BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everc!t,WA 98201 CANCELLED�Y THE CITY UPON ANY STOPPAGE OF NJORK ON THIS <br /> Phona:25�-�f310 PROJECT OV[R 90 DAYS DUFATION. <br />