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oaceL3.L' f�6 <br />Appilcation For <br />PUB�.IC WORKS PERMIT <br />Print or Type Only <br />2 2O 76� s�Sc� Gi <br />ailing Address City <br />v 3s-ls ,i <br />Public Warks Perm • " ������ � <br />emc. 000�. • P "" — <br />Pu011cWo�ksFoe s <br />Totol Fae <br />lasa AOP� Fae PeiA S <br />���n <br />Belnnco Due s <br />� <br />S�7h'� Q Phone <br />Applicent Mailing Address ��h' ZiP <br />Descri6e Proposed Work <br />2 SO/ �uk; ltro P./vd <br />Pio�ect Addrass pt km+wn) - <br />Attach lour (4) copies of plans for proposed work • Dr2H :o scale and note the following as applicable: <br />• Property Lines • Centedine of street <br />• Outline and dimensions of all ezisting and • Indicate North <br />proposed strucWres on Ihe bl . • Show any proposed 5rading chaoges <br />• Existing and proposed utilities • Show measurementa <br />PERMIT CONDITIONS <br />1. All cells for inspeclion shall be made 24 hra in advance • phone 259•881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standerds end Speafications <br />3. Call location Underground Service 48 hrs. brfore you dig. TOLL FREE NUMBER 1-500•424•555$. <br />■!'J <br />% /f-'..I�'./ /�'D�/�-' oS'i.7/ G <br />Approvedt C��structi n ate <br />� ��-� � . �- '�J-��_ <br />FI �NSPECTION Dale <br />qpproved as Consirucled <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEM1IENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersic�ned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett irom any and all claims for damages, costs, <br />expenses, or causes ot action that may arise because ot installation <br />and maintenance ol the improvement or other right•of•way use hereto <br />applied for and further agrees to remove same upon notice Irom the <br />City and to replace public properry damaged thereby. <br />�-��,�, sr�P-�,: <br />z �/v-�6 <br />Signatur ol Applicant Date <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CAt�CEL:ED BY THE CITY UPON ANY STOPFAGE OF WORK ON THIS <br />PROJEGT OVER 90 DAVS DURATION. <br />