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Dete � a� 9� <br />,-z..y�-►�1�91y��� p fld �lY'��*. � <br />t ' <br />Applicatlon For <br />PUBL�C WORKS PERMIT <br />Print or Type Only <br />�r � <br />Atltlress <br />.,�� G..L, <br />r�oi�c wmwc ro�mu .�D _ 36 7 <br />umA oom • <br />PupLCWodefco S <br />TOIPI Foe <br />Lmf �pPl Fex P.1W s <br />Oalince0ae S �rJ�� - <br />DO z-3zz- ya-000- /l- B3/ <br />Zip Phone <br />aF.{ �/- �5.3- 973 7 <br />up rnone <br />Describe Proposed Work Cel�r�r t Cow � c ��r��..� n� i w e"F err e F �!� Ww w.y� <br />sfr ol c�'r� 6 r� 'r-r eu��-�a�.% �f e:'n.�1 �t.r a-f •�+ r..r�.�� Er� Iaa' F,....t;���q,.Y�.y <br />i . � �� <br />u:l� <br />Rwr1 w.��'L S�rrn� <br />Project Address (if known) <br />Atiach lour (4) copies ol plans lor proposed work - Draw to scale and note Ihe following as applicable: <br />• Properry Lines • Canterline ol street <br />• Oulline and dimensions o� all r.isting and • Indicate Norlh <br />proposed structures onthelo' � Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />J <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be performed in accordance with this permit and current City ol Everett Design and Construclion <br />Standards and Specifications. <br />3. Call Location Underground Service 48�hrs. belore you dig. TOLL FREE NUMBER 1$00-424•5555. <br />y �,� � ,� d�t� �� �o��� <br />' �� e-i -90 <br />L. <br />(l'o�'�N 2Z%a`G > <br />A <br />i��o� 8�/90 <br />Approved lor Construction Date <br />FINAL INSPECTION � � �,.-�' -'• ' • ` � Date <br />Approved as Constructed <br />everett PUBUC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phane:259�8870 <br />.< <br />ACKN�LEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save narm• <br />less the Cily ol Everelt Irom any and all claims br damages. costs. <br />e■pen5e5. or causes ol action that may arise because of installation <br />and maintenance of �he improvement or other right-ubway use hereto <br />app�ied tor and lurther agrees lo remove same upon notice irom Ihe <br />Ciry and to replace pu6lic properry damaged thereby. <br />. �=-:y_` � `'1� �'� ia <br />Signature ol Applicant Oale <br />WORK AUTHOR�ZED BY THIS PERMIT MUST BE STARTED WITNIN <br />180 DAYS OF DATE PERMIT IS ISSUE� AND THEREAFTER �S TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PEFiM1T MAY B[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAY3 DURATION. <br />