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S � <br /> . -•-.� I a�`.�.-a <br /> �r <br /> � <br /> ■ I <br /> 7 •'w �-'v r�o��cwo,wew�n. <br /> Date <br /> eiaa o�o�.+ — <br /> ' qpplicotion For <br /> PL6LIC WORKS PERMIT �°°'""'°"„`° <br /> iotni Fea s <br /> Le31 ApP��Fee PaiC S-�— <br /> BaiancaDue S <br /> �c�� Print or Type Only , <br /> [�1 I <br /> x <br /> � �7 <br /> 9 y y Owner Mailing Address * City Zip Phone <br /> � ���''' � �.�a�e� ���,r� <br /> �O H� Appliwnt Mailing Address C�ty Zip Phone <br /> VJ H <br /> � �� �a�}���r�►P r�� � <br /> Oescribe Proposed Work <br /> OH <br /> " �s W�� � <br /> 'Y.y '� �'-t'?)� /��� � . <br /> H <br /> C" M H Prolect Address lil known) � <br /> g � Attach lour(4)copies ot plans lor proposed work- Draw to scale and note ihe lollowing as applicable: � <br /> �"'� • Centedine ol streel � <br /> C] C�W • Property Lines <br /> Q� • Outline and diinensions ol all ezisting and • Indicate Norih <br /> proposetl structures on Ihe lot • Show any Proposetl grading changes <br /> • Ezisting and proposed utilities • Show measurements M <br /> O�n W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> 1.All calls for inspection shall be m3de 24 hrs.in ativ�nce•phone 259•8810. <br /> 2.All work shall be perlormed in accordance wilh this permit and current Citv ol Everett Design and Construction <br /> Standards end Specifications. � <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800�424•5555. <br /> '� � <br /> _� O <br /> �- -, ��� �� '�� I`� N� f /`cz` H <br /> __ <br /> ,-� � ��I �;�-� t/� <br /> i--� 7'G��- p <br /> �- <br /> 2� 5 ��� a <br /> __ <br /> �- - <br /> I ACKNOWLEDGEMENT OF CONDITION <br /> i � <br /> The undersigned owner/applicant hereby agrees�o hold antl save arm� <br /> less the City of Everetl Irom any and all claims for damages, costs, <br /> expenses, o� causes ol action that may arise because of installation <br /> and maintenance o� the improvement or other nghDof�way use hereto <br /> �� <br /> applied for and lurther agrees lo remove same upon no�ice rom t e <br /> Approved for Consiruction Dale City and lo replace public properry damaged thereby. <br /> ' FINAL INSPECTION Dale Date <br /> Approved as Construcled Signalure ol AppGcam <br /> WORK AUTHORI2ED BY Tl115 PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT �g0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS 70 <br /> � 3200CetlarStrem BE DILIGENTLY PURSUEO TO COAIPLETION.THIS PEFMIT h1AY BE <br /> Everet�,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJEC7 OVER 90 DAYS DURATION. <br />