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��H <br />9�y <br />H�� <br />FC Q <br />H� <br />�H� <br />ro � <br />�� <br />�HC7 <br />OH <br />��g <br />�Y (7 <br />t" y Z <br />HH <br />gy <br />H <br />C] t❑7 y <br />p7r�q <br />H t/i <br />H O Vi <br />Date �-��q <br />App�icalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />/ • l�ul�liC �\'p'ks �i.lmil • ._ (� <br />nim� oer� . ��%'� CZOZ.�-2-J - <br />Vu�bcWor�sFer —_--"'__'"_ <br />To�N Fe� 5 — —" <br />1055 A�t�l �1!I• P.11�.1 S <br />2ip <br />e.,i.,���.n,��, s <br />r�' �a n^ � <br />Applicant Alaihng Atldress Ciiy Zip Phone <br />Descnbc ProposeJ Work <br />Pro�ect Adtlresslif knownl —�o�� '^�j" " ' <br />Attach tour (4) coP�es of plans for proposed work � Draw lo scale and note the lollowing as apP6cahle�. <br />• Property Lines <br />• Oull�ne and dimensions 01 all existing antl <br />proposed structures on ihc lol <br />• Ezist�ng and pioposed utilities <br />• Centerline of street <br />• Indicate Norih <br />• Show any p�oposetl gradin9 changes <br />• Show measuremenis <br />PERMIT CONDITIONS <br />1. All calls lor inspeclion shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pertormed in accordance with this permit and current City ol Everett Design and ConsUuction <br />Standards and Specilications. <br />3. Call Location Underflround Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424•5555. <br />Approved lor Conslruelion <br />�� �� _ <br />��j � 9 <br />9- <br />Date <br />FINAL INSPECTION ����' <br />ApPmved as Constructed <br />evrrrtt PUBLICWORKSDEPARTMENT <br />� 3200 Cedar Siree� <br />Everelt, lh'A 98201 <br />Phone:259�8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />�w <br />_ / <br />� <br />O <br />H <br />� <br />O <br />a <br />The undersigned owner/applicant heretry agrees to holtl and s�ve harm- <br />Iess ihe City o� Everelt irom any anr all claims �or damages, cosis, <br />expenses, or causes ol attion that rtay arise because ol in5tallation <br />and mainlenance ol Ihe improvemenl or other ngh4of�way use herelo <br />applied lor and lurther a9rees to ��move same upon notice Irom the <br />Cdy anA to rep�ace publlc property damaged there6y. <br />Signalure ol Applicani Date <br />WORK AUTIIORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF D�TE PERMIT IS ISSUEU AND THEREAFTER IS TO <br />BE DIU6ENTLY PURSUED TO COMPLEiION. TNIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PHOJECT OVER 90 DAYS DURATION. <br />