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DateJ `�'S �'� <br />AppliCation For <br />PUBLIC WORKS FERMIT <br />Print or Type Only <br />Applicant <br />Describe Proposed Work <br />Mailin9 Address <br />ling Address <br />�,�o,,�,vo�.,P��m�,. 9.3 Z � <br />Biaq Depl • _ - <br />PueiicWorksFee 5 <br />To101 Fee <br />LesSIOCL Fee Pa�; $ h <br />Bdl:fp<P �uP � � v� <br />dOZ —,�ZZyO//8�/ <br />3/ <br />c�iv <br />Gty u; rnone <br />P�olecl Address (if known) ��� %� �' �10C LG[J /�/iL � , � /'�C'.E � � y <br />Al�ach lour 14) copies ol plans for proposed wOrk - Draw �o sCale and note the lollowinc� as apUhcable: <br />• Piaperly Lines • CeMerline of streel <br />• Outline and dimensions ol all eaistin9 �nd • Indic2te North <br />proposed s�ructures on Ihe Int • Show any proposed grading changes <br />• ExisUnq and proposed utillties • Show mezsuremenis <br />e1= <br />PERMIT GONDITIONS <br />1. All calls for inspeclion shall be made 24 hrs. m adv2nce • phone 259•8810. <br />L All work shall be performed in accordance with ihis permit and currenl City ot Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />`i.l 1)2Q/' CtiC{ �-���- C-�a�.� a�7` �2,C1(� iZ�t�-.�- <br />/ <br />� <br />S_ �,�=�s-�:.. �.>�.�v�•� <br />c�z�.c��('� ?-�-u��' /.�-� <br />�����o��,�-. <br />i <br />� 7/; '} <br />%+n <br />/%o.z,,�'. S <br />/-.��� � <br />Approved as Consiructed � <br />�PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Evcrett, WA 98201 <br />Phonc�.259�8�t0 <br />� <br />� <br />O <br />� <br />� <br />0 <br />a <br />,1CKNOWLEDG[t�tENT OF CONDITIONS C� <br />The unAersigned owneriapplicanl hcreUy a9rees to hold antl save harm- <br />less the Cdy ol Everett Irom any and all clalms tor dama9es. costs. <br />ezpenses, or causes ol action that may arise because of installation <br />and �niintenance ol �he improvement or other righ��of�way use hereto <br />applled fo� and lurther agrees to remove same upo� nctice from the <br />Cily and to rep�te public property dama�ed thereby. <br />S1i�n, e of App6cant ua�e <br />WOR AUTHORIZE BY THIS PERAIIT h1UST BE STARTED WITHIN <br />180 AYS OF DATE PC-RMIT IS ISSUEU AND THEREAFTER IS �O <br />BE DILIGENTLY PURSUED TO COMPLETION, THIS PERMIT MAY BE <br />CANCELLEU BY THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVEF 90 DAYS DUHATION. <br />