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Uate ��K�S/tJ6 <br />� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />��-�,, N�, �.4„a <br />Owner <br />Describe Proposed Work <br />Pro�ect Addross d� known� <br />S/j3 <br />Nng Atltlress <br />C O. � D. Borr 95��" <br />Mailing Adtliess <br />City <br />� /� <br />�•�,�� < <va,.� n,.,,,,�: . <br />f3ina Dco� • __ <br />PuUM1c Worhf ine <br />Totel Fee S <br />Lesf AOo� Fee Px�tl S <br />eai.�oeo�, S <br />- 9f.Zo3 <br />ZS <br />Phone <br />o•�! J%DCw AL.c <br />Att�ch Iwr �4) �opies of plans lor proposed work - Oraw to scale and note the lollowing as applica6le: <br />� Property Lines <br />• Outline and dimensions ol all existing and <br />proposetl siructures on ihe lot <br />• EKisling antl proposed utilities <br />• Centedme of street <br />• Inditate Norih <br />� Show any proposed gratl�ng changes <br />• Show measurements <br />PERMIT CONDITIONS <br />t. All calls lor inspection shall be made 24 hrs. in advance • phone 259-8810. <br />2. All work shall be pedormed in accordance with this permit and current City of Everett Des�gn and Conatrur.lion <br />Standards and Specilications. <br />3. Call Location Underground Serv'�ce 48 hrs. belore you dig. TOLL FREE NUMBER 1•800-4245555. <br />`f �i�'.oe�' A,uy 5'�a€�..��c ,B.cv,rE,� �.�-'o-�n Ty,s- <br />0����r���✓, <br />Approved as Constiucted <br />everetl PUBLICWORKSDEPARTMENT <br />� 3200 Cedar Street <br />Everell WA 99201 <br />Phonc:259•8810 <br />- 9i�� <br />ACKNOWLEDGEMEN7 UF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />0 <br />a <br />The unAers�9nec1 owner/appGcaM he�eby agrees to hold antl saec• h�rm� <br />Iess Ihe City ot Everell Irom any �nd all claims lo� damages. costs. <br />expenses. or causes of action Ihat may anse because ot mstallation <br />antl mamtenance of ihe improvement or other nghPobway use hereto <br />anPlied for and further agrees to remove same upon noGce Irom ihe <br />City antl to replace pubhc property damaqed thereby. <br />� 3�zz�° 5 <br />Signaturc ol ApPlicant ' Date <br />WORK AUTI�OHiZED BY THIS PERMIT �r1UST BE STARTED WITHIN <br />180 DAYS OF DATF PERMIT IS ISSUE-D AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />