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_��-- <br /> Date�� - - ---- <br /> _ _ -- — — - — —v� <br /> � �. <br /> APPlicatioi� For ' P�m�cworx,pe,m;�, <br /> - PUBLIC WORKS PERMIT B�a� ��P� + � a�- <br /> Pu01ic Wo�ks Fap <br /> 7ota1 Fee S'- <br /> Print orType Only TO POSTING 2�2�5 �1� �esaAppLFeaPgid s.�_ <br /> . <br /> � ealence Oue <br /> � -����� S-� <br /> v /5l� <br /> ner Mai{ing qddress �� ��� ��ap` <br /> City Zip ��"� <br /> i, 9 Phone <br /> c.v��� <br /> Applicant <br /> Mailinp qddress <br /> City Z.P <br /> Phone <br /> Describe Proposed Work C <br /> u <br /> � <br /> Project Address(if known) � /„ � i, <br /> cGC <br /> Attach lour(q)copies ot p�ans for p�oposed work• Draw fo scale and note the foilowin as a � <br /> • Property Lines 9 Pplicable: <br /> • Outline and dimensions of all existing and � Centerline of street � � <br /> proposed structures on the tot � �ndicate North � <br /> • Existing and proposed utilities • Show any proposetl grading changes <br /> • Show measurements <br /> DO NOT Wq�TE BELOW 7HIS LINE ' m <br /> PERMIT CONDITIONS <br /> 2.All olrk shall be pe�rformed n accordance with this pe mitand c�u�r59�88y�Everett Design and Construction O <br /> Standards and Specifications � <br /> 3.Call Location Underground Service 48 hrs,before you dig.TOLL FREE NUMBER 1-$pp-424•5555. <br /> /�� ` � �.c (r-/3-%/ � <br /> /�G�C-G'� �G•�JLl�e3� n.�.�i�-�-{ �(� r <br /> , ���„ �_� <br /> � L�..,I <br /> � � <br /> T« �nr-�u=<"�_�, � <br /> 2-� ,o���.��;� �,,,� � <br /> � r0>-iC,wt� S�c,�e�'. S_c«.L .�-�q.ru?.,�� �i Clf_C. <br /> .2Fq�cu u.,-..e�y , ��� O <br /> 0 <br /> a <br /> ACKNOWI,EDGEMENT OF CONDI710NS <br /> The undersigned owner/applicanl he�eby agrees to hold and save harm• <br /> less the City of Everett irom any and all claims for damagr.s, cosls, <br /> expenses, or causes ol action Ihat may arise hecause of installation <br /> AUProved tor Constiuction and mainlenance of the improvement or other righf•of•way use herelo <br /> Date applied for and lurther agrees to remove same upon notice trom the <br /> Cily and to rep�ace public property damaged thereby. <br /> FINAL INSPEC710N <br /> Approved as Constructed Date �, ' � <br /> Signature ol AppliCant � <br /> PUBIIC WORKS DEPqqTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WI7HIN <br /> 9200CedarStreet 180 DAYS OF DA7E PERMIT IS ISSUED qND THEREAFTER IS TO <br /> Everett,Wp ggpp� BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLED BY THE CI7Y UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJFCT OVER 90 DAYS DURATION. <br />