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Date 3 � � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Unly <br />1N <br />Owner <br />Describe Proposed Work <br />Pro�ect Address �if known) <br />Address <br />Vut�Lc 1vo�4s Permil • � /�/ <br />Oia9 �en� • - f.� <br />bcWodsFpu s <br />iotel Fea <br />Less ApPI Fee Paid S n'1 <br />Belan[eUua S eV� <br />� �_ 981 ss 3 6�-'f�1� <br />CiP;� Zi� Phone <br />��!Y Zip Phone <br />Attach tow (4� copies of plans lor proposed work - Draw to scale and note ihe lollowing as applica6le: <br />• I�roperry Lines <br />• Outline and dimensions ot all existing and <br />proposed slructures on ihe lot <br />• Existing and proposeo utilities <br />• Centerline of strect <br />• Indicate Norih <br />• Show any proposed gradin� chan�es <br />• Shnw measurements <br />PERMITCONDITIONS <br />1. All calls for inspection stisll be made 24 hrs. in advance • phone 259-8810. <br />2. All work shell be performed in accordance with this permit and current City ol Everetl Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore y�u di9. TOLL FREE NUMBER 1-800•424•5555. <br />�z.d��l�- �/9/ge <br />Approved lor Cons clion Date <br />�' �� / /� <br />/ ��_ <br />FINAL INSPECTIJN ' Date <br />Approved as Construc�ed <br />everett PUBLICWORKSDEPARTMENT <br />� 3200 Cednr Street <br />Everen. WA 98201 <br />Phone.259�0810 <br />ACKNOV�'� EDGEMENT OF CONDITIONS <br />W <br />F- <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersignetl owner/applicant he�eby ac�rees 10 hold and save harm� <br />less the Cdy ot Everett Irom any and all claims for dama9es. costs. <br />expenses, or causes ol action that may anse because ol installalion <br />and maintenance of Ihe improvement or othar nghFohway use hereto <br />appli�d for and lurther agrees to remove same upon notice Irom �he <br />Clty and to replace public property damaged Ihereby. <br />� -� . _ . .. , , . . _ <br />—(/ liri-�v � � " • . � � <br />Signeture ol Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT A1UST BE STARTED WITHIN <br />�80 DAYS OF DATE P[RMIT !S ISSUED A"�D THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPI_ETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON �NY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />