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Date 7 • / • �3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />oW�e� <br />W�Iic Works Pmmll s � / � <br />Blap. DepL s <br />PuDlk Worke Fea <br />To1N Fee S � O' � � <br />Lea� AppL fee F�IE S � <br />B�I�nce Due S a �. � a <br />$203 2b'q- <br />_DONGLAS �.�nX��ZLSON 4414 GRAN+� Av� ���R�rf 9B2v3 ZSq —Ia63 <br />Applicant Mailing Address City Zip phane <br />Describe Proposed Work <br />_ AOD/ill3M TO �GK�S"(. NDIA1� � �/iSE.!'1�tJT—C�sAKiQ.LIE S <br />ProjectAddress(ifknown) �%'4'14 G2eNA AVIE (G <br />Attach four (4) copies of plans for proposed work • Draw to scale end note the following as applicable: <br />• Property Lines • Center�ine of slreet <br />• Outline and dimensions of all ezisting and • Indicate Norih <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shail be made 24 hrs in advance - phone 259•881 5. <br />2. All work shall be performed in accordance with ihis permit and current City of Everett Design and Construction <br />Standerds end Specificationa <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424-5555. <br />__`���6���i�-- 7- 6 - �3 <br />A oved for Construction Date <br />�—��.�/�"� r-i-�y <br />FIN I SPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Ceder Street <br />Everett, WA 9820� <br />Phone:259•8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/appllcant hereby agrees to hold end save harm- <br />less the City of Everett from any end all clefms for damages, coat�, <br />ezpenses, or causes of action that may arise because of Inetelletlon <br />end meintenance of ihe improvement or other right•of•wey uae hereto <br />applied for and further agrees to remove same upon notice from the <br />City an to replac public property damaged thereby. . <br />� p � �� ' <br />ignature of Applicent Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHiN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />6E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THI$ <br />PROJECT OVER 90 DAYS DURATION. <br />