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71, <br />1 Date—.— . _. Public Works Permit a� <br />91Jp Dear • - <br />Application Foi <br />PUBLIC WORKS PERMIT <br />Less Aral Fee Paid $ 3� <br />Balance Due $ <br />Print or Type Only <br />u: a o <br />P <br />Owner Mailing Address City , t � ZIP Phone <br />'xw <br />Ros�u'T �t,a>L1?ol Nc L'�fiTH -�i1 �1811� 52 i v�'�v <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work c� A5 <br />{'�LrlOu iIGti AT„Q A120QN0-Xf`�lllvC�r sir_ (!�C i�Fr CCi,C CTC- �Jt1�FL}1(K <br />O' ruQ L 4a_C it 1 Er 1'C- -- <br />W <br />Project Address (it known) �7 1 <br />Attach lour 14f copies of plans for proposed work • Draw to scale and note the following as applicable: <br />i'• • Property Lines •Centerline of street /^ <br />i h • Outline and dimensions of all existing and • Indicate North _ v♦ <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements ca <br />DO NOT WRITE BELOW THIS LINE Q <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259.881 O. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />-� Standards and Specifications. <br />3, Call Location Underground Service 48 hrs. before you dig. TOLL FREES NUMBER I.800�.424.5555. z <br />��' �12v«/ /'r�G`rmgf •O/J ���7' 6t{� lQ��.d !�� .ucccdt � c/C2 ,:� O <br />v as ,.fo <br />.� B2U lK 11,g,.Lt7/rt.GQ" RJ 160tgl" - u1'sW AO <br />Appr9dpd for Cp strut a Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />ewvett PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8810 <br />'s ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs. <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and furthe ?r es to remove same upon notice from the <br />City 3 d laJ,� play p/uWrp damaged thereby. <br />igpalure of APPlicant ! Date <br />WORK AUTHORIZED BY/THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE P,ERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />