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Date�" 7 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />���Y <br />cny <br />� <br />Pu�lic Wo�ks Permil • <br />/�� eiao. oea�� • <br />(/��J FuOIICWo�ksFeo S <br />(J Tolxi Fev <br />Loss Aoot Feo Peie S e� <br />Balance Due S J� <br />.zsa-z��� — <br />F'�onn <br />Phone <br />DescribeP�aposedWork l�-u �,�f Gil.ar�w1PN.l�,_�.CFAfI.. �'l—P'(o�� <br />Pro�ect Address (if known) <br />Attach lour (4) copies of piens for proposed work - Drnw to scale and note the following as applicable: <br />• Proporty Lines � Centerline o( street <br />� Outline and dimansions of eil existing and • Indicate NoAh <br />proposed structures on tha lot • Show any proposed grading changes <br />• ExlsNng and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be metle 24 hra in advance • phene 259•881 5. <br />2. All work ahall be performed in acccrdance witl� this permit and cunant Cit/ of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800-424•5555. <br />`r �, //�`aMr� �p /�'1i+3 Od � �'Z' 8% <br />� ��O <br />NAL <br />as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone: 259-8815 <br />Dale <br />ACKNOWLE�GEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/apolicant hereby agrees to hold and save harm- <br />less the City of Everett irom any and all claims tor dameges, costs, <br />expenses, or causes of action thal may arise because of installaticn <br />and maintenaoce of lhe impravement or other right�ohway use hereto <br />applied for a.nd further agrees la remove same upon notice from the <br />Cily � replace public properly damaged thereby. <br />� , <br />//%i�..�/ `1- �.c�p.n-C� a % <br />Signature ol plica S�" Date <br />WURK AUTFiORIZEG BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />8E DILIGENTLY PUFiSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON ANti' STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 GAYS �URATION. <br />