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Date�,..�L� (((777 <br /> Pu�hcWo�ksPormi �� <br /> Application For emA oeo� �� <br /> PUBLIC WORKS PERMIT PuLLcWpd5Fa0 - <br /> .e�a�F�e s <br /> �essApplFoePaW $ __ <br /> Print or Type Only Balqn�c Due s <br /> 1�n�. I� � P�—����� (�n�Y�. /�-�/�e ��,�19- �R2,� I �,�� <br /> Owner Mailing Address City 2ip Phone <br /> L�ls� ��nSt <br /> Applicanl Mailing Adtlress Cily Zip Phone <br /> Describe Proposed Work <br /> �n �� �� T <br /> Project Address�il known) _ � �I � `����� � <br /> Attach fOur(4)copies of plans lor proposed work- Draw to scale and note Ihe followinq as applicable: � <br /> • Property Lines • Centerline of s�reet � <br /> • Outline and dimensions ot all existing and • �ndicate No�ih <br /> proposed siructures on the lot • Show any proposed�rading changes <br /> • Exisling and proposed ulililies • Show measurements � <br /> DO NO7 WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1.A��calls for inspection shall be made 24 hrs.in advance-phone 259-8810. � <br /> 2.All work shall be peAormed in acwrdance with this permit and current City ot 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 /> I��T ��v1��'_D � <br /> `����C G- E -�a (� <br /> � <br /> a <br /> ACKNOWL[DGEMENT OF CONDITIONS <br /> ihe undersigned owner/applicant hereby ac�rees lo hold and save harm� <br /> less the Qty ol Everetl Irom any and all claims lor damages. cosls, <br /> eapenses, or causes ol action that may arise because ol install�;ion <br /> and mainlenance of �he improvement or othcr ri9h(�ol-way use hereto <br /> applieA lor and lurihe� agrees to remove same upon notice from the <br /> Approved for Construction Dale Ciry and to ren���ce Uubhc properly damaged Ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed S�9nature ol Appl�cant p��� <br /> everett PUBLICWORKSDEPARTMENT WORK AUTHORIZ[D BY THIS PERMIT MUST �E STARTED WITHIN <br /> � 3200CedarSlreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PEFMIT MAY BE <br /> Phone:259�8810 CANCELLED BV THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER�JO DAYS DURATION. <br />