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Date v !�cT� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />6L(lG/9�L r ,� � ,QJCnlo, /5 <br />Owner A(nCNj. Me <br />7; N.•k. �aNs;� <br />ApplicaM <br />Describe Proposed Work <br />Project Address (if known) <br />t <br />./N <br />Mailing Address <br />T,N �S'�. <br />PwGc Worka Permit r �/SJ� <br />eiae. ocv�.• _ � <br />vu0lit WorFe Fee Oo• <br />Totnl Fee S _ �T <br />LPaS Appl. FB! PaiC S <br />ea�ance oun S � <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />� Property Lines • Centerline of street <br />• Outline and Aimensions of all existing and • Indicate North <br />proposed structures on the tot • Show any proposed gradina changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone :59•8815. <br />2. A�I work shall be performed in accordance with this permit and curre�t Ci;y of Everett Oesign and Construction <br />Standards and Sper.ilicationa <br />3. Call Location Underground Service 48 hrs. before you di�. TOLL FREE NUMBER 1•800•424•5555. <br />� •�'W/.r/1% <br />Ccm�i.E'o [_� ]--��T <br />��S' �i.c'cz.�o <br />Aproved as Con ;tn _ted <br />evere[t PllBLIC WORKS DEPAFTMENT <br />� 3200 Cedar Street <br />Everett, WA 58201 <br />Phone: 259•8815 <br />c�'f-- i.t1S'/t-�z�r?,� <br />C>— O �d� <br />cc c,y�v���- <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />The undersiyned owneVapplicant hereUy ac�rees to hold and save harm- <br />less ihe City ol Everelt Irom any and all claims fo: damages, costs, <br />expenses, or causes ol action that may arise because of installation <br />and maintenan e ol the improvement or olher right-oFway use hereto <br />aPPlied tor a rther agrees to remove same upon notice from ihe <br />Ciry and to r public property damaged thereby. <br />---LRLJ! L�� i fi " -� a J <br />Signature ol Applicant Date <br />WORI< AUTHORIZ[D BY TNIS PEIiM1T M ST BE STARTED WITHIN <br />td0 DAl'S OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />b� DI�IGE'JTLY PURSUED TO COMPLETIpN. THIS PERMIT MAY BE <br />C.INCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />