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� <br /> � /��i <br /> Date�/���� Pu011c Works Permlt a ✓J L <br /> eiea�oeo�.. <br /> Application For <br /> PUBLIC WORKS PERMIT PUbTo�IFeu�ca $ - <br /> Less Pppl Fec Pald g <br /> . Balancc0ua $ 2n• �� <br /> Print or Type Only 7�3�y ���i <br /> ��E��=,c.. A2nc.O 3z. G-.�.9.�o /IvE' �✓Err�-.-.- 96'�.a� �?.5 - ozS <br /> Ow�er Mailing Address City 2ip Phone <br /> i <br /> S/`I M� Z <br /> Mailing Address Cily Zip Phone � <br /> Applicant � <br /> �1 ' / m <br /> Describe Proposed Work �v T�ND n�/vE l��r 7 <br /> .. .. <br /> -1 -n <br /> W " �' <br /> N 2 <br /> m <br /> 0 <br /> � co <br /> m o <br /> Project Address(il known) ._.�� <br /> � 03 <br /> Attach four(4)copies of plans for proposed work- Draw to scale and note the following as applicable: � r,.i <br /> • Property Lines • Centerline ol street = „Z1 <br /> • Outline and dimensions ot all existing and • Indicate North m � <br /> proposed strucluras on the lot • Show any proposed grading changes ,p Z <br /> • Existing and proposed utilities • Show measuremenls M e <br /> W �_ <br /> DO MOT WRITE BELOW THIS LINE O K N <br /> PERMIT CONDITIONS � � <br /> T T <br /> t. All calls tor inspection shall be made 24 hrs. in advance- phone 259•881 5. <br /> 2, All work shall be perfonned in accordance with this permit and current Ciry of Everetl Design aod Construction = r^ <br /> Slandards and Specifications. m � <br /> � N <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1-800•424•5555. o r <br /> nm <br /> `�, CU.V7.G'd7Qt' /S TO GU�t17A[:� P!/BciG W�'`��S .l✓SVEGTO� O m �+ <br /> AND /�<'•�'.a�c'C-E' Fo•E' A �nEFri.vCr AT TNE S/>E -Zi� <br /> • m <br /> (,t/HE�J %��'i+o j/ Tv 6'EGliv WO/E�e . � n <br /> z <br /> � <br /> � <br /> D <br /> Z <br /> O � <br /> � <br /> N <br /> a = <br /> 0 <br /> � <br /> .. <br /> n <br /> m <br /> ACKNOWLEOGEMENT OF CONDITIONS <br /> � �L The undersigned owner/npplicant hereby agrees to hold and save harm- <br /> R�k'� les; Ihe Ciry o� Everetl irom any and all claims lor dama9es, costs, <br /> . expenses, or causes ot action �hat may arise because ot installation <br /> . / '7 / v and maintenance of �he improvemen� or olher righl-of-way usa here�o <br /> / � C'D'/� V/J/.�S ypplir.d for and further agrees to remove same upon notice from the <br /> Approved for Conslruclion , 4 �� City and lo replace public proper�y damaged lhereby. <br /> ����� l JO-�f� ` . )I��/�. \ <br /> -��i�`�� � �f.i�(,7r -( � � _� � <br /> FINAL SPECTION �a1e � Date <br /> Approved as Constructed Siynature of APPIicaN „ <br /> WORI< AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 1d0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259�8815 PROJECT OVER 90 DAYS DURATION. <br /> / <br />