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i � <br /> � <br /> Date���./ Pu01¢Wo�MaPermn• ��^/�O _ <br /> Application For emq oeo�.• —. --.. <br /> PUBLIC WORKS PERMIT PubhcY/ortsiee -- - <br /> ,o�a�F�e s_ <br /> Less AnD� Fer PaiO a _ <br /> o��T��e o�� s � l/r�.4.�� <br /> Print or Type Only — <br /> �,����« �1u� �.mar� �i�b PD gox aBSI �V�.+rei-� 9'�av3 ��fa -�so� <br /> Owner Mailing Address C�ty � Zip Phone <br /> �►5 � rn,, ���9 a� '�"' prS� Fypr�tt ld'a�8 74a-SS�S <br /> Applicant Mailing Address City 2ip Phone <br /> Describe ProPosed Work ����"'" Q'��.1� ar�-l�1 � Paei '�C, `� <br /> �,p �P �rnc;�n P��I-rr.v�ncA. �o �t-icsr- ve-re aci�t �. I o'✓► ��y12 , <br /> i -k� - r`s rrm 1 �7. ,d 4� <br /> dnoL Saf u l a.c 'j,, <br /> Project Address�if known) Tu'N a �' (� i i� ...�/ S P/NE� � <br /> Attach four(4)copic�:of plans for proposed work- Draw lo scale and note the lollowing as applicable: � <br /> • Propert � Lines • Centerline ol street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed siructures on ihe 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 cails tor inspection sh[ill be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shall be perlormed in accordance with this permit and current City of Everett Design and Conslruction <br /> Standards and Specificati�ns. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBEH 1-500•424•5555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEOGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm• <br /> less the City ol Everett irom any antl all claims for damages, costs, <br /> G��' 'L`� �� , � exPenses. or causvs of action that maY arise because ol inslallation <br /> a' and maintenance ol the improveinent or other right•ol•way use hereto <br /> .Y� 9^r (� <br /> appfed for and further agrees lo remove same upon notice irom the <br /> Approved lor Con truction Date City and to replace public propeCy damaged thereby. <br /> � �i- �99 �,�v,.�o Sab�f�' <br /> FINAL INSFECTION Date o—�--- <br /> Approved as Constructed Si9nature of Applicant —��e <br /> WOAK AUTHORIZED HY S PERMIT MUST BE STAFTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 OAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Slreet 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�8810 PROJECT OVER 90 DAYS DURATION. <br />