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Ciate /%'s• 8�' <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Publ¢ Wm�s PormJ � �_Q=��r <br />B�cl9 DePI a __'_ <br />Pubhc Wprha Fen <br />ioial Fee S <br />LessApO� FqePa�a S <br />Calnnce Durt S ��' C��.Q6'1� <br />CCi9uC/N5 E�vipn��.ur �o • ��7 �/�N�D �!f �a�r.t�r �a� 4�aoi as� •3�oti <br />Owner Mailing Atldress City Zip Phone <br />Applicent Mailing Address City Zip Phone <br />Describe Proposed Work LD / 7 ��//!� �/!! 1,1� �i/UCf' Ll.�� .[�/�.e/3��i �/)/KL GVI/ TQ �% <br />s'1N ,t�iyhT o� cc�� e,� zan�fe <br />Projed Add�ess lif knownl <br />Attach lour (4) copies of plans for proposed wo�k - Draw to scale and note ihr, lullowing as apU�ical�le: <br />• Property Lines <br />• Outline and dimensions ol all ezisting and <br />proposed structures on the lo� <br />• Existing and proposed utilAies <br />• Centerline ol sireet <br />• Inditate Nor�h <br />• Show any proposed gratling changes <br />• Show measuremenis <br />LI <br />PERMIT CONDITIONS <br />7. All calls fo� inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be performed in accordance with this permit and current City ol Everett Design end Construction <br />Standards and Specifications. <br />3. Call Location Underg�ound Service 48 hrs. betore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />fL F� ,-�KE �c<<5' ?— �� //r�J'Ti�'GG `v <br />aiJ ��'.�`'�==�i� �//r� — �>vT �� <br />�G%�'GlC' <br />ion <br />, FINALINSPECTION <br />Approved as Consiructed <br />everetl � PUBUC WORKS OEPARTMENT <br />� c`�. c- L� <br />Date <br />i/- F <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />F- <br />� <br />• <br />� <br />� <br />O <br />a <br />The undorsinned owner/applicant here6y agrees to hold and save harm� <br />Iess the Ciry of [verett Irom any and a�l claims lor damages. cosis. <br />expenses, or causes ot aclion Ihat may arise because ol installation <br />and malnte ance ol �he improvement or other right-of�way use hereto <br />app6ed rfand further agrees to remove same upon notice Irom Ihe <br />City ai Ip replacO'pu}l �fc property damaged Ihereby. <br />�V��% .�,��L' �J � �!"V� ��;j J � <br />SiqnaYure 6f Applicant ' Date <br />WORK �UTIIORIZEO BY THIS PERMIT h7US1 8E STARTED WITHIN <br />