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S! <br />Date `� �� � � <br />� <br />PUBLI� <br />� <br />Print or Type Only <br />�� <br />Tn �nSTINf __ 3- �� - 9 �� <br />Applicalion For <br />WORKS PERMIT <br />Pu01�m Wo�Ms Parmlt • � � � S / <br />eiec. oen�. � <br />Public Works FeB s <br />To�el Fee <br />Less AOGL Pee Paid S� <br />BatanceDue S �yL�'� _ <br />.-� O� O <br />r� Vo OOZ 3Ys"83ia93iy /% 3� <br />°; � � onz - 3z � �o � 4a3/3iY o �9 <br />" �rr W�� 5 <br />� i � G.4Rl� ��FR <br />li�g Ad ress �Z� <br />;�� %1/� ��� ��� P <br />' j� �_ /6'.�a <br />citv ���,,,�� <br />. ...__T � Mailing Address �P <br />Prolect Address (if known) � "— � ' — <br />Attach four (4) copies of plans tor proposed work • Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all ezisting and <br />proposed structures on lhe �ot <br />• Ezistin9 and proposed utilities <br />� Centerline ot street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspeclion shall be made 24 hrs. in advance • Phone 259•8810. <br />2. All work shall be peAormed in accordence wilh this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Catl Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•B00-424•555 . <br />7 GC/�� <br />d2�.o <br />5.r �'e�� <br />�W .02 dt�xa.. �.2 l��9[2�c�% �y,v <br />�/,S/�� . ���y ��f« ���� <br />c. �y Sf��� fs L'L�� a h �� �/_ C t..-.,� s� <br />f0 or/��N<<� CP��C,l7�oh <br />�. �eSf��e Rrc'� J <br />�l(��f� ���— .��s�9s� <br />Date <br />Approved to��,��o <br />�jc�� �=�'�% <br />� �` c ate <br />FINAL INSPECTION <br />Approved as Construcled <br />�PUBLIC WORKS DEPARTMENT <br />3200 Cedar Sireel <br />Evered, WA 98201 <br />Phone::. �d•8810 <br />W <br />H <br />� <br />� <br />H <br />� <br />� <br />a <br />ACKNOWIEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />less the Ciry of Everett Iroc� any and all claims for damages, costs, <br />exper.ses, or causes of action that may arise because of installation <br />and maintenance ot Ihe improoemenl or other righ4obway use hereto <br />applied for and further agrees to remove same upon noti,:e trom the <br />City and to replace public properly damaged thereby. <br />i� , --, , � `� <br />. � � <br />� <br />Dale <br />Signalure of Applicant . <br />WORK AUTHORIZED BY THIS PER IT MUST BE STAFTED WI7HIN <br />180 DAYS OF DATE PEFMIT IS ISSUED AND THEREAFTER IS TO <br />BE DIIIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THt CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PRO.IECT OVER 90 DAYS DURATION. <br />