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i � <br /> , . <br /> . <br /> Date ��a�_�� •.,+v r..�:, v�o�,�w�,.sv<,m�i. <br /> Application For o'ac oeo� •— � ��-� <br /> PUBLIC WORKS PERMIT C�oTotalFer`n° S - ' <br /> 1e53 AD��F!!Pd�a S �. <br /> 13dldnCnDart .S ' <br /> x�� Print or Type Only <br /> ��7yH / � / �� I <br /> ���'x" L 2.t �Dv2 �nG C1n �73 I r.(�Pt"in+ dz�J Lv /,d�- _�k-5�3�� <br /> Hy� p�y�g� h7aJin Adtlress Cdy Zip Phone <br /> y �f-+ <br /> � H� n/i�/11�A <br /> O� H� Applicant Madmc�Address City Zlp Phone <br /> V1 H � � <br /> r ,�� � /�� <br /> � Describe Proposed Work �"�-�--� <br /> � O� <br /> H <br /> H �g � <br /> �,,. " � I <br /> t" H� ProlectAddressplknown) �`��`�Y �r� H � <br /> y Attach tour(4)copies ol plans lor proposed work� Draw to scale antl note the lollowing as apPhcable�. � <br /> N � I <br /> O l7 f/� • Properry Lines • Centerline ol slreel <br /> � �r • Outline and d�mensions ot all existin9 and • Indicate North <br /> [�7 proposetl sirucW res on the lot • Show any proposed grading chan9es <br /> x �3� • Existing and proposed utilities • SI•�ow ineasurements /1A <br /> HOV� 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 he pedormed in accordance with this permit and current Cdy ol[veratt Design and Construction <br /> / Standards and Specifications. <br /> '�_ 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> �� <br /> � �� tao��-s• �i:�:w�/Uo� �1�-v-v.<.��. O , <br /> I �� � <br /> � �� <br /> � �• � 8-z�-f'o � <br /> � O <br /> � ��� � <br /> � � ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hemby agrees to hold and save harm� <br /> less the Ci1y of Everett from any and all claims for damac�es. costs. <br /> expen5e5. o� C3u5e5 (1� aCilon IhO� mdy ari5e beCauSe Of insialll(ion <br /> � � and maintenance of the improvement or other right�ol�way use ��ereto <br /> apPlied for and further agrees to remove same upon nolice from th�� <br /> Appmved lor Construclion ���e City and to replace pu6lic property damayed thereby. <br /> . � <br /> FINAL INSPECTION Date <br /> Appmvetl as Constructed Signalure ol Applicant ���� <br /> WORK AUTHORIZED BV THIS PEf7MIT MUST BE STARTED WITHIN <br /> everell PUBLICWORKSDEPARTMENT 180 D�VS OF DATE PERAIIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200Cedar Sireet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERh11T M1fAY BC- <br /> Everetl.WA 98201 CANCELLED BY THE C�TV UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8810 PROJECT OVER 90 DAYS DURATION. <br />