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� Public Works Pe�mit� � � <br /> Date�/�� eme o�o+.= <br /> Application For <br /> PUBLIC WORKS PERMIT P°°T�WFaaFOe s ��,— <br /> �oss noo�Foe aam S �� <br /> Balance0ue S �—_ <br /> Print or Type Only ,�Z' �li� 7�Z <br /> AI�; � ��il�Hl— �SiIRFD /'l�l►l���l-- ������/ phone <br /> T�' Owner l ` Mailing Address ���Y ZiP <br /> p (�q .1 ( �t,. � y� / f� �ii��t 9��CY� s'c�-�.:��� <br /> �Y/.�ND�A�i�:.��7jV� �Jl / -� . 6('��E��/ Zi Phone <br /> � Applicant ..� <br /> Madmg Address City P <br /> (SM E�u�r•lurR ,��:� �/.�� � KIN� <br /> • �.r J�T �•t�sTl�V6 �id'fi'L`f�,F��4' i�VTrl /� �)���r <br /> Describe Proposed Work <br /> ...- � <br /> W <br /> Proiect Address(if known� <br /> 02�7 3 o C� ak rs � <br /> � <br /> Attach four(4�copies o(plans for proposed work• Draw to scale and note the following as applicable: � <br /> � property Lines • Centerline of sireet <br /> • Outline and dimensions of ali existing and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes � <br /> • Existing and proposed utilities • Show measurements <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � � <br /> 1. All calls for inspection shall be made 24 hrs. in advance• phone 259•881 5. <br /> 2. All work shell be performed in accordance with this permit and current City ol E�ierett Design and Construction <br /> Standards and Specifications � <br /> 3. Call Location Underground Service 48 hrs. belore you dig.TOLL FREE NUMBER 1-800-424•5555. <br /> � ,�-.� ��.� ��� d��-� 6 ao �3 � <br /> � <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEA'ENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hoid and save costs, <br /> less the Cily of Everett from any and all claims for damages, <br /> j expenses, or causes ot action that may arise because c! installation <br /> and maintenance of the improvement or other righ4of•way use hereto <br /> applied for and further agrees to r=mo��e same upon nctice Irom the <br /> Ap roved fo .on ction Date City and to replace public propr.rty d a�ged thereby. <br /> `1�� <br /> �% ���j- ' C��� �-- <br /> MAL INSPECTION Date Date <br /> Si ure ot Applic <br /> Approved as Constructed RK AUTHORIZ BY THIS PERMIT MUST BE STAR1cL WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE P[RMIT IS ISSUED AND THEREAFTER IS 70 <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,VJA 9820t CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259•8815 PROJECT OVER 90 DAYS DURATION. <br /> � <br />