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, <br /> Date �/ ��'- � p I // <br /> �i�� � O 2/ � PuEbc Works Parmit♦ �� ' 7�i�.j <br /> � Application For eia9.oep�.. <br /> PUBLIC WCIRKS PERMIT Fu�uc\VorksFee <br /> Totei Fee S <br /> , lesa AoO�Fee Pa�m s <br /> Print or Type 7nly Bsience0ue s �,/,�.�o0 <br /> P.U.D, Plu. 1 of Snohomish Co., P,O. Box 1107, Everett, !�'q 98206 Jim Sic��son <br /> 347-4317 <br /> Owner Maifing Address City Zip F'hone <br /> P.U.D. General Engineering De�t. <br /> ATTN: Jim Simpson P.O. Box 1107 Everctt, iVA 9S20b 347-4317 <br /> Applicant Mailing qdtlress City Zip Fhone <br /> DescribeProposedWork IdOdlfy BXist�nn �torn drain yc <br /> ten Incra�i *� bacins and �rn� <br /> drain pi�e. Sevaray�; on-a;tP ctorn drain and c nirary cewer P r Dictr• r �t <br /> 81 $ 82. � rs__S�2_8�2,— <br /> � <br /> .�s<az-�=,g,.� .�- W <br /> Project Address(il known) ��+��'$ailte'�1Yenu �_ � <br /> Attach lour(4)copies of plans for proposed work- Draw to scale and note the following as applicable: <br /> • Property Lines � <br /> • Cenlerline ol sireet � <br /> • Outline and dimensions ot all exisling and • Indica;e 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 � <br /> PERMIT CONDITIONS O <br /> t. All calls lor inspection shall be made 24 hrs. in advance•ohone 259•881 5. <br /> 2. All work shall be perlormed in accordance with this permit and current City of Everett Design and Construction � <br /> Standards and Specilicalions. <br /> 3. Call Location Un�erground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424•5555. <br /> � � �E `p�/ST.C'UCTE/J /'E.c; , � <br /> �7 !'�I�h'G(�e Q O <br /> /�L9.dS �79TEp 9�E- 8G <br /> � �YJL G � <br /> J. �.L' INS�ECTili:� .b�EF�C'E� Cc�✓�,�'i/li[,:-' � <br /> .9.uy ,J.,�Fr <br /> O <br /> a <br /> ACKNOWLEDGEMENT Of CONDITIONS <br /> The undersi9ned owner/applicant hereby agrees to hold and save harm- <br /> � less ihe City of Everett Irom any and all claims lor damagec, costs, <br /> l7 expenses, or causes ot aclion ihat may arise because of installa�ion <br /> ��,�� 9���� and maintenance of lhe improvement or other right�obway use hereto <br /> App ved lor �ction applied lor and lurther agrees to remove same upon notice irom the <br /> � � Dale City and to replace public property damaged thereby. <br /> FIN�ECT���'� � / 1 � Da� � �J C �< <�� I�—� <br /> Approved as Constructed Signa re of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHOfiIZEO BY THIS PERMIT MUST �E STARTED N9THIN <br /> � 3200 Cedar Sireet 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Fverett.WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone: 259-8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WGRK ON THIS <br /> PROJEGT OVER 90 DAYS DURATION. <br />