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�� I <br /> f <br /> I <br /> i I <br /> � <br /> Date�� O—I PubL[':!o•ksP !1�/— ZO Z <br /> emq.Dco�.• ---- <br /> Application For <br /> PUBLIC WORKS PERMIT P°°ro,WF�a`�� $ — -_ <br /> less Ap01.Fee PaiO S <br /> eai,��e o�c s 2� , <br /> Print or Type Onty <br /> 7 � � � '� <br /> Owner MaBing Address City Zip Phone <br /> ���-/.�9 , <br /> Applicant Mailing Address City Zip Phone ' <br /> Describe Proposed Work ��/` <br /> -7 --- W <br /> Project Address lif knownl / ��� — yrA ��e �����/ � <br /> i <br /> Attach four(4) copies of plans for proFosed worM- Draw to scale anA note the lollowing as applicable: � i <br /> • Property Lines • Centerline of streel � I <br /> • Outline and dimensions of all existing and • Indicale North <br /> proposed struclures on the lot • Show any proposed grading changes j <br /> • Existing and proposed utilities • Show measuremeNs � <br /> DO NOT WRITE BELOW THIS LINE � I <br /> PERMITCONDITIONS '" �', <br /> 1.All calls tor inspection shall be made 24 hrs.in advance•phone 259•881 O. � <br /> 2.All work shall be performed in accordance with lhis permit and current City of Everett Design and Construcfion <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> O <br /> � I, <br /> NI <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applica��hereby agreEs to hold and save harm- <br /> � less �he City of Everett from any and all c!aims tor damages, cosls. <br /> D�J 4/ �� / ezpnnses, or causes of aclion iha� may arise because of installation <br /> ,�7(�� /' � /f_ / ��(' and maintenance ol the improvr.•��nt o! other right-ol•way use hereto <br /> ��� �� l��t��- r� / applied for and further agrees P� t�nove same upon notice Irom the <br /> Approve or Constructi n /- �a�e Ciry and to replace public propr��r damag?d Ihereby. <br /> s� / / �� , �/�9/��, <br /> .1NAL SP TION� ` afe � �����J Date � <br /> Approved as Constructed Signature ol Applicanl <br /> WC�RK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everet[ PUBLICWORKSDEPARTMENT �g(� DAYS OF DATE PERMIT �S ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sireei gE DILIGENTLY PURSUED TO COMPLETION. THIS PERA1!( MAY BE .. <br /> Everett.WA 99207 CANCELLED BY THE CITY UPUN ANY STOPPAGE OF\NORK ON THIS <br /> Phone:259-8810 PHOJECT OVER 90 DAYS DURATION. <br /> I <br /> I <br /> � <br /> I <br /> I <br /> � <br /> i <br />