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Dates>`�`'`' s <br />Application For <br />PUBLIC WCIRKS PERMIT <br />Print or Type O�ly <br />_.0� ohh <br />Owner <br />Mailinq Address <br />City <br />PUEIic WorFa Permil � V� 4 7/ <br />Bl�p. DepL � <br />Publ¢ Works Fee <br />Tatel fee f <br />Leaa Rppl Fea Pa1E S h <br />Balantt Oua s LQ �d <br />,� <br />'�' <br />% q3 �� <br />i� �i 3���, z.�"�� <br />Phone <br />/1 . L S��Fj � <br />Phone � <br />Describe Proposed Work �����-.'b .� /� ViS �'f��� ���' Y clt���p /Qy�f <br />d <br />Prolect Address (if known) <br />Attach fou: (4) copies of plans for prnposed work - Draw to scale and note the following as applicaMe: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />• Cenl^rline of streef <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. AII calls lor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be pertormed in accordance with this permil and current City ol Everett Design and Construdion <br />Standards and Specifications. <br />3. Call loca�ion Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />`. �.�TF.�� /Z �� C'v� v�,�T i.v oiTC.s� A T <br />GE<tsr 3:0 5�' d�at�v Eo�' c�F <br />�.eo�bSE.O li.Pi�G-�/.a s/ ., <br />/ <br />~ l- )�'✓l�^/ �d'a"/rJi <br />Approved lor Consiructi� Date <br />_ �—►/t t/y�� � 10 "O � <br />fff7AL INSPECTION Date <br />Approved as Consiructed <br />everetf PUBLIC WORKS DtPARTMENT <br />� 3200 Cedar Sireet <br />Everett. WA 98207 <br />Phone:259-8875 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />� <br />� <br />� <br />a <br />The undersigned owneUapplicanl hereby agrees to hold and save harm- <br />less ihe Cily of Everett Irom any and all claims br damages, cosis, <br />expenses, or causes ol action that may arise because of installation <br />and maintenance of the improvement o� other righ;�al�way use hereto <br />applied for and lurther agrees lo remove same upon no�ice trom ihe <br />City and to replace puC�ic property dama�' d ihereby. <br />� 7 � .� �j 7 J��.'�� �� q , '' r ; �` <br />,���,_ <br />Signature of Appl�ant Date <br />WORK AIITHQR(ZED B1' THIS P �v11T MUST BE START[D WITHIN <br />180 DAYS OF DATE PER�71T IS`ISSUED AND THEREAFTEF IS TO <br />6E DILIGENTLV PURSUED TO CO�APLETION. THIS PERMIT MAY 8E <br />CANCELL!'J BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVFR 90 DAYS DURATICIN. <br />� ' - __ _ _r_�ii' .�_ <br />H M <br />H �+] <br />N� <br />�� <br />M � <br />� 2 <br />M <br />� � <br />[t] H <br />N <br />� <br />. �i <br />� <br />� <br />H <br />N <br />� <br />Hn <br />i�i <br />