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Date <br />qppliwtion For <br />PUBLIC WORKS PERIdAIT <br />Pu���c wmke Permit + _SC����L� -i�--� <br />eiao o�o��+ <br />Pumic Worhf Fe+ s � <br />Totol Fee <br />Lefa ADG� Fee PaiC s�� <br />BlIP�ClDV! s� <br />Print or Type Only �� 7�'� <br />6 L� � �e, ,, c ,.- _ <br />Describe PropOsed Wotk _ <br />v�C��T�ti �,V9 F-li l`l��`LI—,wn <br />Prolect Address (il known) .^ • <br />Attach four (4) copies of plans br proposed work • Draw to scale and note � Cco11eWine of sl�eet a�le: <br />• Property Lines • Indicate North <br />• Outline end dimensions ot all existing and � Sho". any Proposed grading changes <br />proposed struclures on the lot • Show measuremenls <br />� Exisling and proposed ulilities <br />PERMIT CONDITIONS <br />1, All calls for inspection shall be inade 24 hrs. in advance - phone 259•881 . <br />2. All work shall be pertormed in accordance with this permit and current Ciry ot Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 40 hrs. belore you di�. TOLI FREE NUMBER 1•800•'-�24-555 . <br />Date <br />.�� <br />Dale <br />as Constructed <br />everett PUBUC WORKS DEPARTMENT <br />`� 3200 Cedar S�reet <br />�t Everelt. WA 98201 <br />��' Phone:259�8815 <br />W <br />H <br />� <br />� <br />� <br />� <br />ACKNO'NLEDGEMENT OF CONDITIONS <br />The w�dersigned owner/applicant hereby agrees to hold and save costs. <br />less lhe City ot Everett trom any and all claims br damages. <br />ezpenses, or causes ot action �hat ma•/ arise becausr o� install�lion <br />and maintenance of the improvement or other right-o6way use herelo <br />applied tor and I rlher agrees to remoaged tharebyn nolice Irom the <br />Ciry and lo re e public property <br />� ' �7� � <br />� Date <br />Signal re of ApPlicant <br />80RDAYSTOORDAT�E PERMIT ISESSUED AND THEREAF ER ISHTO <br />BE DIUGENTLV PURSUED TO COh1PLETION. THIS PERMIT MAY BE <br />� PROJECT OVER 50 DAYS UURATIGN STOPPAGE OF WORK ON THIS <br />�+ � <br />y �: <br />H � <br />� e' <br />� �. <br />r� C <br />O �: <br />� r. <br />�j F <br />C : <br />� � <br />K' <br />t <br />