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i <br /> Dateg����1 �` ^ �(��� <br /> Fimi�c�vo�ws ae�mn a <br /> AnPI1C2liJ0 FO! . 01�9 DeO� � —�/�G�ZL.� <br /> PUBLIC WORKS PERMIT P°°��W°�MSFee — <br /> t��a�«� s <br /> LessAnpl Fee Pa�a 5_ <br /> Print or Type Only B��a�=�o�o s <br /> �ruy1 p ��,�f ('� �'o ��1z�n ��in�P�I ��n(�, asa sraig <br /> Owner Mading Atldress Cdy Zip Phone <br /> �$WL e' — <br /> Apphcant Mailing Address Ci�y Lp Phone <br /> Describe Proposed�4'ork ��.�p��iM/,]I(i�e,/N//1 T' 7Ni/' YI^U(��n �,ry � JN y <br /> � <br /> Project Address(il known) _ pZ�� � `u���! �V`� __ � <br /> � <br /> Attach four(4)copies ol plans lur proposed work- Draw to scale antl note�he lollowir�as applicable: � <br /> • Pioperty Lines • Center�ine ol street � <br /> • Outline and dimensions of all ezisting and • Intlica e Norih <br /> proposed struclures oc the lol • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRI�E BELOW TNIS LINE <br /> IPERMITCONDITIONS O <br /> 1.All calls for inspoction shall be i iade 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shall be pedormed ia accordance with Ihis permit and current City of L'�.vzrett Design and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.bebre you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> O <br /> �� C' ���-' �-�' Il �1� �l �C�L-,�j� � <br /> � -� - ��e( � <br /> �=�`C.�tia��� p. <br /> ACKNOWLEDGLMENT OF CONDITIONS <br /> 7he undersigned owneriapplican�hereby agrees to hold and save harm� <br /> Iless the Cdy ol Everet� Irom any and all claims lor damages. cosis. <br /> expenses, or causes of adion that may arise because of installation <br /> and maintenance ol Ihe improvement o�other righFol-way use hereto <br /> Approved lor Construction Date 3�Plied !or and furthcr agrees to removr. same upon notice Irom the <br /> Gty aed to replace pubhc proprrty damaged ihereby. <br /> FIIJAL INSPECTION Da�e <br /> Approved as Consirucled Signalure ol Appl�cant Date <br /> everett PUBLIC WORKSDEPARTMENT VJORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CeAarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFiER IS TO <br /> Everetl,WA98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> V'ROJECT OVER 90 DAYS DUqATION. <br />