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i <br /> I <br /> I <br /> � � <br /> Y <br /> u yp_�9e <br /> Date "� //��/9�t Pu01ic Wo�ksPermn• <br /> Biag.DepL• <br /> � qpplication For <br /> � <br /> pU�IC WORKS PERMIT Publ¢WcrksFeo <br /> iotal Fee s <br /> S lessAppl Fea Paltl � �f <br /> —oa—_ <br /> SOp Balence Dua s CQ� <br /> Print or Type Only,� N N <br /> N <br /> N N <br /> M <br /> �]�Rv�N � ��L� ? 30� DAI<PS �Venr�T �'( ff2ol <br /> Owner � � �� Mailing Address City Zip Phone <br /> J � � �� <br /> Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work °� � <br /> `� W <br /> Project Address�if known) Q � - <br /> Attach four(4)copies of plans for proposed work- Draw to scale and note the tollowing as applicable: � � <br /> • Property Lines � Cenlerline of streel � <br /> • Outline and dimensions of all existing and • Indicate Norih � <br /> proposed structures on Ihe tot • Show any proposed grading changes � <br /> • Existing and proposed utililies • Show measurements M i <br /> DO NOT WRITE BELOW THIS LINE O I <br /> PERMIT CONDITIONS <br /> 1.All calls tor inspection shall be made 24 hrs.in advance•phone 259•8810• � I� <br /> 2.All work shall be peAormed in accordancc with this permit and current City of Everett Desi9n and Construction <br /> Standards and Specifications. <br /> 3.Cali Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> `l,� S.?f !�P a rnse�fi.�y Gui�/i fhe Ci�yi �v6lie G�/nr�s� O <br /> /�S�G foi' ��o.z •c� �fi�y qhy wo��f. <br /> �ee ca„d QFf4ch�c/� � <br /> ., � ����� JO <br /> v� <br /> ^ �l ��� �7P 5 _ � `� � �� G a <br /> � fAN . l" ��C� �� <br /> �G�� ��/� � � cy , <br /> (/oul� � � n� CKNOWLEDGEMENT OF CONDITIONS <br /> � The undersigned owner/applican�hereby agrees lo hold and save harm• <br /> less the City of Everett from any and all claimc tor damages, costs, <br /> expenses, or causes ol action that may arise because of inslallation <br /> ' /Ll� `� 9p and mainlenance ol the improvemenl or olher right�of�way use hereto <br /> f P9 applied tor and lurther agrees to remove same upon notice irom the <br /> Approved lor struction , � 1 ��e City and to replace public property damaged thereby. <br /> `/ o � � l,� .2 7 9 � � <br /> ..�-�',� �-�c�-�i� <br /> IN L INSPECTION a� Date <br /> Approved as Consiructed Signature ol Ap icant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPAR7MENi 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Eveiett,WA 98201 CANCELLED BY TI�E CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8810 PROJECT OVER 90 DAVS DURATION. <br />