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��n(,,,/�O�/` PUGIie Workf Pe�mit e <br /> DateT� �r 7v'�`/ <br /> ApplicationFor eiau.uen��+ ��� <br /> PUBLIC WORKS PERMIT PueTo�FeeFee s <br /> Leaa AO��fee Pald S <br /> eaienca Due S <br /> Print or Type Only <br /> �e��rt �, �� IF�e ��a�� h�q .�i� �o�t �-sa - � yi� � <br /> Owner Mailing Address —�City Zip Phone <br /> ��fl�r�. � <br /> Applfcant Mailing Address City Zip Phone <br /> Describe Proposed Work <br /> C<=—c=--k2r <br /> M H <br /> H "+1 <br /> Pro�ect Address(if known) �� �� � ����""�"� - � m � <br /> V .3 <br /> Attach four(4)copies of plans for proposed�.vork- Draw to scale a�d note the following as applicable: � p <br /> • Property Lines • Centerline ot street � y <br /> • Outline and dimensions of all existing and • Indicate North [�j <br /> proposea structures on the lot • Show any proposed grading changes Z <br /> • Existing and�roposea utilities • Show meesurements � y <br /> DO NOT WRITE BELOW THIS LINE y ~ <br /> ri N <br /> PERMIT CONDITIONS � � � <br /> 1. All calis for inspeclion shall be mede 24 hrs in advence•phone 259•887 5. <br /> 2. All work shell be partormed in accordance with this permit and current City of Everelt Design and Construction <br /> Standards and Speciflcations y <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> //p� O � <br /> /Y (�' Pl/�G�C `�i'o���..— � � � <br /> � ', .�� � ��. �� - <br /> ��z:� ������ / � � <br /> / � / � � O � <br /> /,UU it.��..v ,dCc'cFss 7vf�',�c�P�-'rY �il � ° �=— „ <br /> ` � � <br /> a � <br /> H <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agraes to I�old and save harm- <br /> less the City of Everett from any and all clalms fcr demages, costs, <br /> expenses, or causos of action that mey arise becauue of installation <br /> and maintenance of lhe improvement or other right-of•way use hereto <br /> applied for and further agreos to remove same upon nolice irom the <br /> Approved for Construction �a�e Ciry and to replace public proUerty damaged ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signalure ol Applicant �o�e <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTIIORIZED BY THIS PERMIT MUST B[ STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sireet BE DILIGENTLY PURSUED TO COMPLCTION. TIiIS PERMIT MAY BE <br /> Everelt,WA 98201 CANCELLED BY THE CITV UPO�ANY STOPPAGE Of WORK ON THIS <br /> Phone: 259-8815 PROJECT OVER 90 DAYS DURAIION. <br />