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Date`�•G a3 / � , <br /> Pu�lic WOrks Permit y� �� <br /> Application For ama 000c. f3� /!`/%-� <br /> PUBLIC WORKS PERMIT PUO7otalFeoFco S <br /> LessAoni FeoPaitl S � <br /> Print or Type Only or����eo�a S <br /> �,i 1-,a �Ic�� ,��l (Ja�� � , �� 7 G 7 <br /> bwner �' ( f/�.l( v//l !�� �S/'�7�n � <br /> Mailing Address City Zip Phone <br /> �- �'���\/4 r 11"'i�I,����_�LFLII.��C�� �I"(CitY �� Z�� �l)� ��c�. )J7 J <br /> ^� Mailing Address <br /> P Phone <br /> Describe Proposed Work �O ` ,� ,�� �� �X '�-1 ) /��; 1 x <br /> �E_,�,.�r <br /> � � Projec;Address(if known) 1 � L . �` � <br /> � Attach lour(4)copies of plans for proposed work• Draw to scale and note the following as applicab'e: � <br /> � • Property Lines O Centedine of street <br /> • Outline and dimensions of all existing � i • Indicate North � <br /> proposeJ structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements <br /> . � ' DO NOT WqITE BELOW THIS LINE � <br /> ; PERMITCONDITIONS O <br /> 1. All calls lor inspectlon shall be made 24 hrs. in advance-phone 259•887 5. <br /> 2. All work shall be performed in acwrdance with this permit and current City of Everett Design and Construction � <br /> Standards and°necilicetions <br /> 3. Call Location Undarground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. <br /> 7• /�/��Py MI/S� fif �PPf C�P�i dM(r.n¢ ab.,S�iuc�ioh � <br /> / ,� 0 <br /> F- <br /> � <br /> O <br /> . a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undcrsigned owner/applicant hereby agrees to hold and save harm• <br /> less the City ol Everetl from any and all claims for damages, costs, <br /> !L� expenses. or causes of action that may arise because of installation <br /> S��, �3 and maintenance ot the improvement or other nght-ohway use hereto <br /> pproved lor Construction Dale applied lor and lurther agrees to remove same upon notice irom the <br /> Cily an r e public property damaged thereby. <br /> FINAL INSPECTION �_/� _�3 f <br /> Approvetl as Consiructed Date <br /> Signatwe of Ap � ant �- Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHO ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everelt, Wq gg201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8815 CANCELLED BY THE CITY UPON ANY S70PPAGE OF WOP,K ON THIS <br /> � PROJECT OVER 90 DAYS DURATION. J <br /> L <br />