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.� <br /> Datei�.�n'�D � �� <br /> r�oe�wo,ks va S, r 31 <br /> Application For Bieo�Deot• <br /> PUBLIC WORKS PERMIT Fu�I�cWarksFee <br /> TolalFee S�� <br /> Less App�Fee Paitl S-_ <br /> Print or Type Only Balance Due S�� <br /> �(�l -�� �,rY�__1� �/��tl� I �j / ('+, <br /> Owner MailingAddress �+-�IL� �X�� � ��� �f�� <br /> City Zip Phone <br /> k k <br /> Applicant Mailing Address City <br /> Z'P Phone <br /> Describe Proposed Work _ �������������/ <br /> C <br /> Project Address(if known) � <br /> Attach four(4) copies of plans lor proposed work- Draw to scale antl note the following as applicable: N <br /> � Property Lines � Centerline ol slreet _ <br /> • Outline and dimensions of all existing and • Indicate North � <br /> proposed structures on the lot • Show an <br /> � Existing and proposed utilities Y P�o�osed grading changes <br /> • Show measurements <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERMIT CONDITIONS O <br /> 1.Ail cells for inspection shall be made 24 hr,,in ativance•phone 259•8810. <br /> 2.All work sheil be peAormed in accordance with this permit and current City ol Everett Desic�n and Construction ' <br /> Stendards and Specifications. <br /> 3.Call Location Underground Service 4B hrs.bsfo�e you dig.TOLL FREE NUMBER 1•800•QQ4•5555. <br /> `�' . k�CT�UV� /\N l7 �CI�IZCC t=-X c STl f�lG f�2�v�{,lA i A f�ic:G:N � <br /> (JI`! "�}4C lV 6�,'�t S 1 D� C�� �Cz�1ThG� W 1 Tit C�r=.g O <br /> c��7-r�-n ;�,� s � D��n�� PEIz. c � T,.t sn� f� 3oCe +3� /�/� <br /> S� ( N 5�1t� N El�l Dn. I v�fv,1�( <ktaZ-e�i.l �, V♦ <br /> �Z t,i'r'-t Sil� 3� O <br /> �k1f�k�M�M W �Dt� = zd � J <br /> a <br /> ACKNOWLEDGEMENT OF CONGTIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less Ihe City of Everett Irom any and all claims for damages, cosls. <br /> �� �,y_^ expenses, or causes of action that may aiise because of installation <br /> -F�( 3��/� and maintenance of the improvement or other righl-ol-v:ay use hereto <br /> Approved lor Construchon —�— applied lor and lurther agrees fo remove same upon notice from the <br /> =�L=�---., City and to replace public proPerty damaged thereby. <br /> ���--� , <br /> FINAL INSPECTION Date <br /> Approved as Constructed �-� ' (J S 9' �� <br /> i nature / pplicant Dale <br /> everett PUBLIC WORKS DEPAR7MENT ORK AU7HORIZED B THIS PERMIT MUST BE STARTED WI7HIN <br /> � 32UOCedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> EveretL WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259-BB10 CANCELLCD BY THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION <br />