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Date�00 ""(r- IZ-Z'8^¢ C/ <br /> 7 Puouc Woree Pa/.�mn� �14�i5 <br /> Application For e�eo oeci..�1��/ � Q� <br /> PUBLIC WORKS PERMIT �ubbcWorheFee <br /> Toial Fea s <br /> Less Aopl.Fee PUC s <br /> Babnce Due f 1��� <br /> Print or Type Only <br /> /� Rt.��.� � vLl� rn , , //�0o7- 7�P,L,Sf �a�eS�even� 9b'?s$ �4/l�y/ <br /> pW�e� Mailing Address Gty Lp Phone <br /> l,t��_��ae.s .sa,vnP, a s �l�vr <br /> Applican� Mailing Address City 2ip Phone <br /> Describe P�oCosed Worh //P u!��!'��1 7 n 7—�] <br /> W <br /> Project Address�if known) �9 3Z �1(�� (.�(A`� ��E � <br /> Attach four(4)copies ol plans for proposed work- D�aw�o scale and note Ihe lollowmg as applicable: � <br /> • Property Lines • Centerline ol sireet � <br /> • Outline antl dimensions nt all eaisting and • Indicate Norfh <br /> proposed structures on���e I�t • Show any proposed gratling changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WPITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> t.All calis tor inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shall be perlormed in accordance with this permit and current City of Everett Design and Constrvction <br /> Standards and Speafications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•B00•424•5555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> .n ACKNOWLEDG[MENT OF CONDITWNS <br /> �,11 U <br /> �w lhe undersigned owner/apnhcant hereby agrees to hold and save harm� <br /> less the Ciry ol Everett Irom any and all clalms for damages, costs, <br /> expenses, or causes of actlon that may arise because o� installation <br /> �� nA�y_� 1U' iZ�q.� and mainlenance ol the impruvement or other right-obway use hereto <br /> 11'! �xx. �� appfied lor and further agrees to remove same upon no�ice from ihe <br /> Approved lor Constr wn Date City and to replace pubGc pwperty damaged Ihereby. <br /> ....�/l��ti!/ 3 ._z'd _`�j � � GGCQ� /¢� <br /> FINAL INSPECTION pate ��� // 1�� "'Ol/ �2—I�� /� <br /> Approved as Constructed Signature ol ApPfcant Date <br /> WORK AUTHORIZED BV THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CetlarStreet BE DILIGENTLV PUHSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Everett,WA 90201 � CANCELL[D OV TH[CIIY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAVS DURATION. <br />