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{ <br /> � <br /> � <br /> I <br /> i <br /> Date��9r/ PubLc Wmks Pormil� � <br /> B�Og.Depl.� �a�� <br /> Application For <br /> PUBLIC WORKS PERMIT PueTotnlFeeFea S <br /> � Lass noo�.Fee Pxie � <br /> Balarce Ouo $ <br /> Print or Type Only <br /> ��,��. �- n'Jo 13,� �S ,- ��� �'f�,,�� P��r as�- �6.�� <br /> Owner Mailing Address City ZiP Phone <br /> _� �D — <br /> qpP�i�y�� Mailmg Address City Lp Phone <br /> DescribeProposedWork ���4�� ')�M �� J� /�/p ""/��/U�d/� '� <br /> WII <br /> Prolect Address lif known� H <br /> Attach four(4)copies of pians lor proposed work- Draw to scale and nole ihe lollowing as applicable: � <br /> � Properry Lines • Centerline of street � i <br /> • Outline and dimensions of all existing and � Indicate North <br /> proposed structures on the lot • Show any proposed grading changes �, <br /> • Existing and proposed ulilities • Show measuremenis /M � <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259-8810. � <br /> 2.All work shall be performed in accordance with this permit and airrent Cily ot Everett Design and Construction <br /> Standards anA Specilications. <br /> 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800-424-5555. � <br /> O <br /> �8�i L L��02.K.� {�G�ZM lT �Ot � � <br /> 5 -�g. -� � <br /> .�� �c�- O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less lhe City ol Everetl Irom any and all claims for damages. costs. <br /> expenses, or causes ol action that may arise because of installation <br /> and maintenance of lhe improvement or other right-of•way use hereto <br /> applied for and further agrees to remove same upon notice Irom the <br /> Approved for Construction Date City and to replace public properry damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature ol Applicant Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BG <br /> Everett.WA 98207 CANCEILED BY THE CITY UPON ANY STOPPAGE OF WORK ON 7HI5 <br /> Phane:259-8810 PROJECT OVER 90 DAVS DURATION. <br /> � <br /> I <br /> I <br /> I <br /> I <br />