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� � 'V <br />C 1-i <br />��� <br />�9�� <br />��o1j� <br />M <br />�� <br />Q�y• <br />tsi N <br />C' y <br />N <br />W <br />�� <br />O � <br />; �� <br />� <br />Date �'z4-9� <br />ra <br />Applicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�^ Puoi�cworherermn. <br />� emo oew. • "� 1�ZZ L`i 6 <br />Pubbc worhe Fee <br />Tolel Fee s <br />Less Ano� Fee PeiC S <br />Balanca0ue S <br />L.Tho�Son I(D30 {Io��jr�K,O.�.Eve.rt.tt98z�3 3'�-l�-(D-!d� <br />Owner Mailing Address City Zip Phone <br />�� <br />Describe Proposed Work <br />Project Address (if known) <br />Attach lour �4� copies o� P�ans br proposed work - Drew to scale and note Ihe following os applicable: <br />• Property Lines • Cen�erline ol streel <br />• Outline and dimensions .,1 atl existing and • Indicete North <br />proDosed structures on the lot • Show any pwposed grading chanyes <br />• Existing and proposeE utilities • Show measuremen(5 <br />3=9 <br />Phone <br />PERMIT CONDITIONS <br />1. All ce�le �or inspection shall be made 24 hrs. in advance • phone 259-$81 �. <br />2, All work ahall be peAormed in accordance with this permit and cur�ent City ol Everett Design and Construction <br />Stend¢rda end Specilicat�ons. <br />3. Call Location Undarground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•80o-424•5555. <br />f i�VJ��C ���UY�CS t-�'r✓v��� ✓lU'£. r'e.r.�.,.v"ec{ <br />Approved lor Construction Date <br />FINAL INSPEC�ION Date <br />Approvetl es Consiructed <br />�PUBLIC WORKS DEPARTMENT <br />3200 Cedar S�reet <br />r Everett, WA 9t201 <br />Phone: 25,�8810 <br />Co-ZCc—S� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />H <br />� <br />� <br />a <br />The undersigneA owner/applicaM hereby agrees to hold and save harm� <br />less the Ciry of Everett M1om any and all claims br damages, costs. <br />expenses, or causes oi action that may arise because of inslallation <br />and maintenance ol ihe improvement or other right-ol-way use hereto <br />npplied lor and further agrees to remove same upon notice Irom Ihe <br />City and to replace public property damagetl Ihereby. <br />Signalure ol Appliwnt Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUE� TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />� <br />