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,�'F,dr 70 «F rn�i� <br />Date <br />3�z- e 7 �- -9 -e � <br />� <br />. � Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�7"O/�e f JU%tv� (o�o/.s /� <br />Owne� MaiNng Address <br />S4N.e <br />Applicant Mailing Address <br />Deecribe Proposed Work S2 w e r �',� g �U �u ��e x /o � <br />�--.._ ..._ ._---- , <br />Pro�ect Addresa (if known) <br />PuElic Works Permit r ____(�� <br />BICp.Dept • <br />aoenc wo�k. Fe. : � �1 <br />Tot�l Fee �1 <br />Lesn ApO� Fa� Ptl0 Q q <br />B�I�nn Due S L� <br />� Attach four (4) coD�ea ot plana for proposed work • Draw'to scele and note the following as applicable: <br />• Property Lines • Centerline ot street <br />- • Outllne and dimensions of all existing and • Indlcate North <br />, propoaed structurea oithelot • Show eny proposetl grading changes <br />• Ezistinq end proposed utilities � • Show measurementa <br />�ss-a� � � <br />rnone <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for innpection shall be made 24 hra in edvance - phone 259•881 5. <br />2. All work shall be peAormed In accordance with this permit and current City of Everett Design end Construction <br />StandeMe and SpecHicetions <br />� 3. Call Locatlon Underqround Service 48 hrs. before you dig. TOLL FREE NUMBEN 1•800�424•5555. <br />�, � 'm-�n s.�� �r���- C��� st�'�dz,� ��04 <br />9 � s1 �� <br />Date <br />Approvad as Constructed � <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Ceder Street <br />Everett, WA 98C01 <br />Phone: 259•8815 <br />W <br />H <br />� <br />� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owne�/applicant hereby agrees to hold end seve harm- <br />�ess the Cily of Everett irom eny and all claims for demeges. costs. <br />expenses, or causes of action that may arise because of instellation <br />and maintenence of the improvement or other righhof•wey use herelo <br />applied lor end further agrees to remove same upon notice irom the <br />City and to replace public propeAy damaqed thereby <br />�� � <br />Signature of A plicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />iB0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIuENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON AN'f STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUFATIOIJ. <br />