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Date �V 7 I PubOc Woiks Perm�l r <br /> Application For eiea oeo�.• cP��� <br /> PUBLIC WORKS PERMIT P�����W�«5F8e — <br /> .o�o�Fea s <br /> Less Aoa�Fee PaiO S <br /> Balanco Dun s <br /> Print or Type Only <br /> �IPvi MD� N�S I�ilrGuc% p��l.�.. �„e.�tl� �id'�� LS Z�2 �� <br /> Owner Mailing Address City Zip Phone <br /> I�UP -{'� Ca�� �- 7/S�/�.� •liE nn��u�/�1���� 33y a�4�� <br /> Appiicant Mailing Address Ci Zip Phone <br /> Describe Proposed Worh ��� /�py� p«�,r�.Q11?�2 <br /> W <br /> Projec�Address(if known) � <br /> Attech four(4)copies ol plans for proposed work- Draw to scale and note the following as applicahle: � <br /> • Property Lines • Centerline ot streel � <br /> • Outline and dimensions of all ezisting and • Indicate North <br /> proposed structures on the tot • 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 for Inspection shall be made 24 hrs.in advance•phone 259•881 O. � <br /> 2.All work shell be porformed in accordance with this permit and current City at Everett Design and Construction <br /> Standards and Specifications. <br /> 3.CaII Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800�424•5555. � <br /> ��G�f�-c�� CUoz�r�,��i,,�f/U,�� , O <br /> �� � <br /> O <br /> a <br /> ACKNOWLEDGEMENT UF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everett from any and all claims lor damages. costs, <br /> expenses, or causes of aclion that may arise because ol installation <br /> and maintenance of the improvement or other righl�ot•way use hereto <br /> applied lor and further agrees to remove same upon notice Irom the <br /> Approved tor Construction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signalwe ol Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CederStreel 1B0 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett WA9B201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLED B'f THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />