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Date '� S' $3 Pu�l¢WorM Parmlt• �� /�" <br /> Application For Biee Dept.r_ <br /> PUBLIC WORKS PERMIT P°°To„F;;`°° : i�ss. 9� <br /> � <br /> Leae aoGl.Fee vaia f / - <br /> BalenceDue S��S�• �Y <br /> Print or Type Only <br /> SE .�. �orp. .Z�3o �Keke�c E.�+. 9'/.za � e?S?-/S`)3 <br /> Owner Mailing Address City Zip Phone <br /> �.aora� C n„��-r. �. 1�.0. �cx 1 �9 9 Eueaeff 48 zoi ?56- 3bb�_ <br /> Applicant Mailing Address City Zip Phpne Z <br /> 0 <br /> I (� .�. <br /> DescribeProposeaWork/� �Na�f. nCw fPs � AHra� W/ f2� ah�.Y Ov� -5��� m <br /> aV.3+ a� -3ti� UtvP�o �Oe.+,r..�- •. <br /> � 1 T <br /> N 2 <br /> m <br /> Project Address(it known) ��+�( �Q-C� �� �'''�• � c v <br /> m o <br /> Attach four(4)copies of plans tor proposed work- Draw to scale and note the following as applicable: e � <br /> � c <br /> • Property Lines • Centerline ol sireet n -�- <br /> • Outline and dimensions ol all exisling and • Indicate North --� z <br /> proposed siructures on the lot • Show any proposed grading changes = �i <br /> m <br /> • Existing and proposed utilities • Show measdrements � � Z <br /> c <br /> DO IvOT WRIT[ BELOW iHIS LINE � i <br /> PERMIT CONDITIONS O < � <br /> T <br /> 1. All calls�or inspection shall be made 24 hrs. in advance- phone 259•86�b. o A <br /> 2. All work shall be perturmed in accordance wAh this permit and current City of Everett Design and Construction � '� T <br /> Standards and Specifiwtions. -� ^� <br /> 3. Call Loca�ion Undr.rground Service 48 hrs. br.fore you dig.TOLL FREE NUMBER 1•800•424•5555. � m .-� <br /> � <br /> 0 <br /> � �PK��-�'. o.. _ s:� � .,�.. o(�� - s;�c .,�...Prv�e....r...�s �er � o� m <br /> wrO�a.ns c...�,�rovPc� �'� � N <br /> � z � <br /> -i r <br /> � m <br /> n <br /> � <br /> � � <br /> x <br /> a <br /> O Z <br /> --� <br /> � <br /> a � <br /> Z <br /> 0 <br /> � <br /> � <br /> � <br /> m <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicanl hereby aBrees to hoid and save harm� <br /> — less the City ot Evereq trom any and all claims la damages, costs. <br /> expenses, or causes of action that may arise because of installation <br /> _��"_�3 znd mainlenance of the improvement or other right-of-way use bereto <br /> proved for Construction � Date ap lied lor and IuAher agrees to remove same upon notice lrom the <br /> r,__ 7 / �� Ci andYo re��lace public property demaged �hereby. <br /> � �, ' �uG�^"� S^�- F y �� � > � <br /> `�I � a <br /> AL INSPECTION Date y <br /> Approved as Conslruded S � ate�e of �pplica " Date <br /> everett PUBLIC WORKS DEPARTMENT � �K AUTHDFIZED HIS PERMI MUST BE STAFTED WITHIN <br /> � 180 DAVS OF D!�T PERMII" IS ISSUED AND THLREAFTEfl IS TO <br /> 3200 Cedar Street / <br /> ��e�e�� WA 9Hza� DE Dll'3ENT�V PUFSUED TO COMPLETION. THIS PERMIT MPY BE <br /> Phone: 259-8815 CANC[LLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PRO,iECT OVER 90 DAY'S DURATION. <br /> 1 <br />