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Date��i <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�s <br />owner <br />Applicar.t <br />.�SS �- <br />na Atldress <br />! b ItL�4.tI <br />r,�i�i�c wo�ws a��mn . �— <br />�iou oaa� . —�?� / �/ 7 % � <br />Pu�i¢WorAaFee s <br />Toinl fae <br />LP55 Appl. FBB PP�4 !s <br />Bd1811CB DIIC i <br />,�. Ei/eReIT 9�: 0 3 <br />r ZiP Phone <br />✓,rli/r//r 9Po7L �i�,� y/%3 <br />� Lp Phone <br />Describe Proposed Wqrk ����EiZi �TorQi'¢6F.�2c'�- l�rti�e/�-�J �7 <br />� X i s rS�rJ�� .Qc'� . / G D �' o�'T <br />Project Address �il known) <br />Attach lour (4) copies of plans lor proposed work • Draw to scale and note the lollowing as applicable: <br />• Property Lines • Centerline cl slreet <br />• Outline and dimensions ot all existing and • Indicate Norlh <br />proposed siructures on ihe lot • Show any proposed gradiny changes <br />� Existing and prcposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be pertormed in accordance wilh ihis permil and current City ol Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800-424-5555. <br />�i/d�G/C G��O�-S f �,ni�,�T /f/O% <br />Approved lor Consiruction <br />k�Ui.E'FO <br />��j� <br />, / z� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />F- <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />ihe undersigned owner/applicant hereby agrees lo hold and save ha�m- <br />less the Ci�y ot Evereti Irom any and all claims lor damages. cosis, <br />expenses. or causes ol actlon that may arise because of installation <br />and maintenance of ihe improvement or other righbol-way use hereto <br />applietl lor and lurlher agrees �o remnve same upon notice Irom the <br />Date City and to replace public property tlamaged Ihereby. <br />FINAL INSPEC710N Date <br />Approved a^, Construr.ted <br />everett PUBLIC WORKS DEPARTMEN7 <br />� 3200 Gedar Streel <br />Everell. WA 98201 <br />Phone�.259-8815 <br />Applicant <br />Datc <br />WORK AUTHORIZED BY TH!S PEFMIT MUST BE STAqTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMF�ETION. THIS PERMIT M�V BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURdTION. <br />