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Date��1 <br /> PupL:Works Permi • <br /> Application For B�dq.DeO�-• <br /> PUBLIC WORKS PERMIT POTofalFeeFee S <br /> Le>s Apol Fee PaIE S <br /> Print or Type Only Baianco D�e s <br /> R►� �c�pr �i I l-����� A�ir- v�� � � �l <br /> Owner Mailing Address Cit <br /> Y Z�P Phone <br /> K�nnP� ""�wnn�il �ayD'� ('�S�l'lt� /��l ���F�� g��t�3 �� 9 <br /> Applicant �_ Mailing Address C�ty Zip Phone � <br /> Describe Proposed Work , �i/_/1 � � <br /> W <br /> Project Address(if known) � <br /> Attach four(4)copies of plans for proposed work- Draw to scale and note the following as applicable: � <br /> • Properry Lines • Centedme of street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed siructures on the lot • Show any proposed grading changes <br /> • Existing and proposed uti�ities • 3hoN� measurements � <br /> DO NOT WRITE BELOW THIS L�NE <br /> PERMIT CONDITIONS O <br /> t. All calls for inspection sha;l be made 24 hrs. in advance• phone 259•S81 5. � <br /> 2 All work shall be Performed in accordance with this perm�' znd currenl City ol Everclt Design and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 4B hrs. belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> ,�U>'�./G C��o.e'.c=� C��.�iT N•�" ,('fn�i���, a/�/g� O <br /> `��/ �- <br /> , <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm• <br /> less the City ot Everett from any and all claims for damages, costs, <br /> expenses, or causes ot action that may arise because of mstallation <br /> and maintenance of the improvement or other right��f�way use hereto <br /> applied lor and turther agrees to remove same upon notice irom the <br /> Approved for Construction �a�e City and lo replace public property damaged thereby. <br /> FINAL INSPECTION Date �uu�,(X //u��-a.-�.y!+¢t�..� ��9 /p', <br /> Approved as ConsUucted �Signature ol Applicant � �T'— <br /> everett PUBLIC WORKS DEPARTMENT �4'ORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everetl,WA 98201 BE DILIGENTLY PUFSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Phone: 259-8815 CANCEI.LED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />