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� <br /> Date�J PuD1ic Worka Parmlt• <br /> Blaq.uno�.• <br /> Application For <br /> PUBLIC WORKS PERMIT PU�ToIaIFoeFae S <br /> Lesa Appt Foa Pa�C � <br /> Beiance Due S <br /> Print or Type Only <br /> l�A�IIEC � Lo�d�'� �303 oR� A,%. �✓-� 9��0� �9-r'�778 <br /> Owner Mailing Address City ZiP i�Phone O `/ <br /> LC�c9,e/� �.J/—✓/�oT <br /> i <br /> s�v� � <br /> Applicant Mailing Address Cily Zip Phone <br /> Describe Proposed W�rk -T�ISTdLG NFL�� �.2��'F� iG� �L/T n'� <br /> ?� .P.D t'-r — <br /> W <br /> Prolect Address(il known) ��v 3 ���'�� ���G•, � <br /> Attach four(4)copies oi plans lor proposed work• Draw to scale and note the following as applicable: � <br /> � Property Lines • Centerline of sireet � <br /> • Ou�line and dimensions of all existing and • Indicate Norlh <br /> proposed structures on the lol • Show any preposed grading changes <br /> • Existing and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls tor inspeclion shall be made 24 hrs. in advance• phone 259-881 5. � <br /> 2. All work shall be performed in accordance with ihis permit and current City o' Everett Design and Consiruction <br /> Standards and Specificalions. <br /> 3. Call Location Underground Service 48 hrs. before you dic�.TOLL FREE NUMBER 1-800•424•5555. � � <br /> '� �� t�7 <br /> �.7n,9'lL[�� /'n _,� O <br /> X/•' r_�--'�- ' <br /> ✓" �� ���c�'"LG�iwY j`" E�n.C. �.3, ��. �s�� � <br /> ,, i,1«.i ,5�, � � � <br /> �lr �/n f'E,���n,T Fc.e A D.t'iv f i JL/ /�{s.'s�.c o�c,v' � � <br /> •��C �`n•J � f ��.l�i]CL C3F C+•«_'ANTFU L•p%/E•r'E ,p6dSo�.'ABt.E O [-� <br /> F!,-�CSS ANI� /NGkE�� F''� T.fE P1y.zr'o�E � � <br /> F� rr:Ni�l� Ti+� /'�n�E� :�/'S �ISED� CAN6'E a �3 c <br /> SEc ��..EU F.enn� iNE ��cE� r �?Oc 'y o �. <br /> � ./,� %�- � � . <br /> �',c �'/ O/ �J <br /> J / �p r <br /> ACKNOWLEDGEMENT OF CONDITIONS C � <br /> The widersig❑ed owner/appBcant hereby agrees to hold and save harm• � F. <br /> less the Ciry ol Everett Irom any and all claims tor damages, costs. � �' <br /> expenses, or Causes of aCtion lhat may arise beCause of installati0n � <br /> and main;enance Of the improvement or other right-obw2y use herero � 2 <br /> applied for and luriher agrees to remove same upon notice trom ihe �, <br /> Approved tor Construction Date City and to replace public property damaged ihereby. <br /> r -� <br /> r <br /> FINAL INSPEC710N Date � <br /> Approved as Constructed SignaWre of Applicant Date �� <br /> WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN Z �. <br /> everett PUBLIC WORKS DEPARTMENT 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS 70 '-3 <br /> � 3200 Cedar Street BE DILIGEN7LY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett WA 98201 CANC[Ll[D BY THE CITY UPON ANY STOPPAG[OF WORK ON THIS <br /> Phone' 259-BBt 5 PROJECT OVER 90 DAYS DURP.TION. <br />