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/� 35• Z9- � <br />Date I"� c� <br />Applicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />/ [, <br />, <br />PubLc WorM9 Py 7�� j��j "']'/j CJ � 4 <br />B��q DeC� � _J����� <br />Pubhc Wurh� Geo <br />TOIRI�PC S _ <br />LesS Rppl. Fee Pai� s <br />n <br />Balance0uc S ��L <br />Hoaress <br />Describe Proposed Work — 1 f�� L 7 71-1'-�, <br />Project Address lif known) <br />Attach lour (4) coples of plans for proposed work - Draw lo scale and note the lollowing as applicable: <br />• Property �ines <br />• Outline and dimensions ol all existing and <br />proposed structures un Ihe �ot <br />• Existing and proposed utilities <br />Approved lor <br />• Centerline of street <br />• Indicate Norih <br />• Show any oroposetl qrading changes <br />• Show measurements <br />PERMIT COIJDITIONS <br />1. All cal,s for inspection snall be made 24 hrs. in advance • phone 259•8810. <br />2. All work ahall oe peAormed in accordance with this permit and current City ot Everett Design and Construction <br />Standards and �peciticatiuns. <br />3. Call Location Underground Service 48 hrs. oefore you dig. TOLL FREE NUMBER 1-800-424-5555. <br />Approved as Consiructed <br />everett PUBUC WORKS OEPARTMENT <br />� 3200CedarStreet <br />Everett, INA gA201 <br />Phone:259�8810 <br />�'<: /- <br />D2:r <br />_���;/ _ S�� <br />Datc <br />ne <br />ACKNOWLEDGEMENT Of COKDITIONS <br />W <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />Tne unders�qned oH•ner/applicant hcreby agrees to hold and save harm- <br />Irs; u�a Gity ol Everett Irom any and all claims �or damages, wsls. <br />°a +��ns-s. c� rauses ol artien Ihaf mav �rise because of installation <br />�� i man ;rn3nce ot �he improvement or o�her righFof�way use hereto <br />�UP'��-d �or and lurther a!7rees to remove same upon notice Irom �he <br />Cit)� antl-�� lic ProP damagetl IherebY. <br />SignaWre ol A(plicant ate <br />WORK AUTfiJRIZED �Y THIS PERMIT �fUST BE STA TED WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGEiJTLY PURSUED TO COMPLETION. THIS PEFMIT MAY BE <br />C�NCELLcD BY THE GTY UPUN ANY STOPPAGE OF WORY, ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />