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Date i9-9c Public, Works Permd • O T <br />Application For r+ 40STING 5 - LS'i 5 slag Dept. <br />PUBLIC WORKS PEt IT P° Total Fee Fee <br />cW Fee <br />t esa Appt Fee Paid �— <br />pO p O <br />O Q Belanca Due <br />Print or Type Onlyto— <br />a « M <br />/Q Co o <br />GUs %NR/J rbi✓r<< J 76%a //A1 nFsan/ F. Yc�CC rr 9� >3 3J t - aio n <br />Owner Maikng Address 5City Zip Phone <br />Applicant Mailing Address pity Zip Phone <br />Describe Proposed Work <br />I�,4 ,Vn Sr_^PE /id Ch hCv ,Qr 'r''W✓ I'v A;`Aci G`/r .1-.re&L-SH <br />_ - <br />r <br />Project Address (if known) 7z'?aso <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of sleet <br />• Outline and dimensions of all exis,ing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <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 251.8810. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 furs. before you dig. TOLL FREE NUMBER 1-800-424-5555. z <br />S cv�t= <br />c cam[ <br />Appr d for Constructio Date <br />r}j I)J 00 .fl C (7�-- 4 ► �S <br />PTNAL INSPECTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />Everett. WA 98201 <br />Phone:'59-8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs. <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace ublic properly damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />