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., <br /> _ "1 � <br /> 1 <br /> - � <br /> ' Date �-S'—dy. <br /> PuElic Waike Permil s 8`� 3 <br /> Application For eieo.oeo�.. � � <br /> PUBLIC W6RKS PERMIT <br /> Puplic Worke Fae <br /> TOISIFee S <br /> Lua RppL Fee Peip S��� <br /> Print or Type Only Balence D�e S�_ "� <br /> PG�GC. .�uulr /�a� � �'IA .wc U�r+..� 1�� El/- Q�i.�D <br /> Owner U Mailing qddress / �f1^S�D3 <br /> Ciry Zip Phone <br /> �crYya /5'iL .�.c.� TY/C t.� �'.2e/ <br /> Applicant 4�C �• .,�r&^�//7/ <br /> Mailing Address City <br /> Z�p Phone <br /> Describe Proposed Work _ �.g�f{ <br /> ,i . <br /> Projecl Address(if known) -�-� - � � �L Z i �' � � <br /> w��.,e V/c.., � <br /> Attach four(4)copies ol plan;lor proposed wo�k-Draw to scale and note the lollowing as applicable: <br /> • Property Lines — <br /> • Outline and dimensions of all existing and � Centerline ol street � <br /> proposetl structures on the lot � �ndicate Norih <br /> • Existing antl proposed uti!�ties • Show any proposetl grading changes <br /> • Show measuremenis <br /> DO NOT WRITE BELOW THIS LINE m <br /> PERMITCONDITIOVS O <br /> 1. All calls for inspeclion shall be made 2q hrs in advance•phone 259-8815. <br /> 2. All work sha:l be performed in accordance wilh ihis permit and current City oi Everett Design and Conslruction ' <br /> Standards and Specilications <br /> 3. Call Location Underground Service 4g hrs. belore you dig.70LL FREE NUMBER 1-$00•424-5555. <br /> ��� � ,�� <br /> �O .1 R �/�_ b�n /u O <br /> / / <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> —�— The undersigned owner/applicant hereby agrees to hold and save herm• <br /> less the City of Everett irom any and all claims lor damages, costs, <br /> � expenses, or causes ol action Ihal may arise beceuse of ir.c;a;lation <br /> / ,f"' F�/ and maintenance ol ihe improvemont or other right�of-way use hereto <br /> �� �.istruc�� Oate applied for and further agrees to remove same upon notice from ihe <br /> City and to replace public property damagetl thereby. <br /> , FINAL INSPECTION �d d/ � � <br /> Approved as Conctructed Date <br /> Signature of Applicbnt Date <br /> everett PUBLIC WORKS DEPAR7MENT WORK AUTHORIZED BY THIS PERMI7 MUST BE STARTED WITHIN <br /> � 3200CedarStreet 1B0 DAYS OF DATE PERAIIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,Wq g8201 BE DILIGENTLY PURSUED TO COMPLE710N. THIS PERMIT MAY BE <br /> Phone:259-8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> , PROJECT OVER 90 DAYS DURATION. - � <br /> r <br />