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� <br /> ��� �� �ubLCWo�ASPer / /�/ <br /> Date—IL�L � <br /> BlfgDcO�-• '-1--���—_ <br /> Application For <br /> PUBLIC WORKS PERMIT P°°°°W°�°=�°� --- <br /> Totnl Fee $ <br /> less Anol Fee Paia $ <br /> p0 <br /> Oalance D�c S �� <br /> Print or Type Only <br /> �l�hr�ld �+�-�r W� �'m n� �i.�ret� ��'� I a59- 7/aa <br /> ^ Owner Mailing Atldress Gty Zip Phone <br /> �'u�- r�5 �� � ���__�,�1�j Z�i��' 4&�3 <br /> Appllcant Mailmg Address ��_"7 I/,� <br /> / �<J <br /> Describe Proposed Work �'� `"'�+ — <br /> W <br /> Project Address(if known) � � <br /> Attach four(4)copies of plans for Groposed work- Draw to swle and note the following as applicable� r <br /> � Property Lines � Centedine ol streel � <br /> • Outline and dimensions ol all existing and • Indicate Norih <br /> proposetl structures on Ihe lot • Show any preposed gratling changes <br /> • Ezisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All cells for inspection shall bo mede 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shall be performed in accordance with this pe�mit and current City of Everett Design and Construction <br /> Standerds and Specilications. <br /> 3.Call Location Underground Service 48 hrc.before you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> 1� _ ACKNOWLEDGEM[NT OF CONDITIONS <br /> IN�J <br /> /�— The undersigneC owner/applicant hereby agrees to hold and save harm- <br /> �� less the City ol Everett from any and all claims for damages, costs. <br /> � eapenses, or causes of action that may a�ise Uecause ol installation <br /> �'l�l 1/1,���� i -� ,_,_ � "��y� and maintenance of lhe i9 provement or olher right-of-way use hereto <br /> �L �( � �' pplied lor and furihcr a rees to remove same upon notice Irom ihe <br /> Approved lor Cons uction ate City, nc lo replace publ c property damaged thereby. <br /> // I % <br /> �l.� I 7' - /G'-J�CJ ,�\ � � // i. � <br /> PINALINSPECTION Date ��%� -GrL-�tc. �� r �- �'��� <br /> Approved as CpnsVucted SlgnaWre ol Ap icant Date <br /> WORK AUTHO�ZED BY THIS PENMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COh1PLETION. THIS PERMIT M11AY BE <br /> Everet[,WA 98201 CANGELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON 7HIS <br /> Phone:259�8610 � PROJGGT OVER 90 DAYS DURATION. <br />