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Q — �^�^� �'3 D / <br /> Date S-5—Q4 a�eucworksaermn• <br /> Application For � � � eia9.oeo�.• 4�SQ� <br /> PUBLIC WORKS PERMIT P�b�,=Wo�ksFea — <br /> ,o���Faa s <br /> Less ApO�Feo Peid $ <br /> Print or Type Only ea�a��eo�e s f4�' <br /> Ken Berg Construction 17902 43rd Ave NE Arlington WA 98223 337-7836 <br /> Owner Mailing Address City Zip Phone <br /> Owner <br /> Applicant Mailing Address City Zip Phone <br /> � Describe Proposed Work new house <br /> Prolect Address(if known) �`"f� � r8l�r- VY � <br /> Attach four�4)copies of plans for proposed work• Draw to scale and note�he following as applicable: � <br /> • Property Lines • Centerline of street � <br /> • Outline and dimensions of all existing antl • Indicate North <br /> � proposed siructures on the lol • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1.All calls lor inspection shall be made 24 hrs.in advance•phone 259-881 O. � <br /> 2.All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specificallons. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 7-800-424-5555. � <br /> 1' P3VL �YiJLW� —�v7.�M Gd�G 0-F rJ2��D/•i-L �'1 �IJW -�v �'U . ���u{_ O <br /> �m hL�� <br /> � <br /> � <br /> � <br /> a <br /> � ACKNOWLEDGEMENT OF CONDITIONS <br /> tJ <br /> _r �/� /� The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less tha City ot Everetl irom any and all claims for damages, costs, <br /> expenses, or causes of action Ihal may arise because of installation <br /> �/1/' L(�� �—i2�2 and maintenance of ihe impwvemenl or olher righ4ohway use hereto <br /> � applied for and luriher agrees to remove same upon notice from the <br /> Ap�roved for Construction Date City�id to replace bGc roperty damaped thereby. • <br /> �.l'l(�L� (�J�/--�L^-' 7'�i��'1`�7 .0 L 'C.L� <br /> F�NAL INSPECTION Date ' � � <br /> Approved as Constructed � nature ol Applicant Date <br /> ���� PUBLICWORKSDEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 3200CedarSireet 180 DAYS OF DATE PERMI7 IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8E <br /> Phone:259�8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOFK ON 7t�IS <br /> PROJECT OVER 90 DAYS DURATION. <br />