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� <br /> Date�g3 Pu�licWadsPormil+�� (� <br /> ema 000��•�� <br /> Application For <br /> PUBUC WORKS PERMIT PubliCWorkaFee �� Q �� <br /> To�a�Fea s <br /> �ass aov�Foo Pe�a S <br /> eaiance oue S ' � <br /> Print or Type Only <br /> �t�N� �. o� �o� P� �r• 9� 3,� 3�>0 - <br /> Owner Mailing Address Ciry Z�P Phone <br /> 5�1�'�� �s—�1"r"✓� Z{ Phone <br /> Applicant M1'311ing Address City P <br /> Describe Proposed Work <br /> C�n1S'?���T" C�S�` �l� 6Rl�d�E Us� �K�T�`/��6 <br /> c�/��� � <br /> r <br /> W <br /> Prolect Address(if known) <br /> � o • � �'� w�- �'� 1-- <br /> � <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 dimensions of all existing and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremr.nts M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> i <br /> PERMIT CONDITIONS � <br /> 1. All calls lor inspection shall be made 24 hrs.in advarce• phone 259•881 5. <br /> 2. All work shall be performed in accordance with this permit end current City of Everetl Design and Conslruction <br /> Standards and Specilications � <br /> 3. Call Local�on Underground Service 4B hrs. befo:e �ou dig.TOLL FREE NUMBER 1•800•424•5555. <br /> I.v li�.,,,(�f.�„!� GYY� Iv/Ltl O <br /> , � <br /> . � <br /> _v O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm• <br /> A less ihe Ciry of Everett Irom any and all claims for damages, costs, <br /> /�� // exPenses. or causes of aclion that maY arise because of installation <br /> � ` ✓r-� and mainterance ol the improvemenl or other righbohway use hereto <br /> ,�v 2 —�3 aPPlied for and further agrees to remove same upon notice trom the <br /> ro�or onslruction ' Date City and lo replace public property damaged thereby. <br /> Q s �'�`� �. __� Y:�_ K"o^� �`�-. <br /> FINAL INSPL'CTION Date Date <br /> Approved as Constructed Signature ot Applicant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everet: PURI.IC WORKS DEPARTMENT 1g0 DAYS OF DATE PERMIT IS ISSUED /.ND THEREAFTER IS TO <br /> � 3200 �edar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everetl,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259•8815 PROJECT OVER 90 DAYS DURATION. <br /> I <br />