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DateJLL�� P�o�,�.•,o...v9, �. '�n��� �6�' i <br /> AppliCaticn For siaq oeo�.• ��i =' L J- I <br /> PUBLIC WORKS PERMI'T Pu�LclYonsFee - <br /> Total Fee S I <br /> Less Aoo� Fee PaiC $ <br /> 1 <br /> Balaete Due 5 'a� 'i <br /> Print or Type Only I <br /> �l r�r�►v� ArrY1 i t�Ct�' 2�1�y ��P, i ps� ��I I <br />' Owner t MaiHng Address Gry Zip Phone �I <br /> � iy� �� � �tvcl r�� l ��a�o <br /> � <br /> qpplicant Mailing Address City Zip Phone��'1(.� � � <br /> O�✓ <br /> DeSCribe ProFosed Work ����`�_ � <br /> W ' <br /> �� y � �� o <br /> Project Address 1if knownl H � <br /> Attach four�4)copies ot plans for proposed work• Draw to scale anC nole the following as applicable: � � <br /> • Property Lines • Centerline of street � � <br /> • Outline and dimensions of all ezisting antl • Indicate North <br /> proposed structures on the lot • Show any proposed gratling changes � <br /> • Enisting and proposed utilities • Show measurements � f <br /> DO NOT WRITE BEIOW THIS LINE O � <br /> PEPMIT CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in edvance•phone 259•8810. � <br /> 2.All work she�l be peAormed 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 FREE NUMBER 1-800-424•5555. � <br /> O <br /> � <br /> � I <br /> o ! <br /> a ��� <br /> ACKNOWLEDGEMENTOFCONDITIONS I� <br /> The undersigned owner/applicant hereby agrees to hold and save harm- �, <br /> less the Ciry ol Everett Irom eny and all claims for tlamages, costs, �I <br /> • ezpenses. or causes of action that may arise because of installation I <br /> G /�� �S �8 and maintenance of the improvement or other right•ol-way use hereto <br /> O'o7 app��ed for and lurther agrees to remove same upon notice irom the <br /> Approved lor Constru �e City and to replace public property damaged thereby. <br /> t'l�// -� �-C� �['.J� � �n.....-+�C.7 I <br /> FINAL INSPECT N Date <br /> Approved as Constructed ignature ol Applicant �a�e I, <br /> WORK AUTHORI2ED BY THIS PERMIT MUST DE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS Of DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarSlreet BE DILIGENTIY PURSUED TO COMPLETION. THIS PERMIT MAY 8E <br /> Everelt,WA 9920t CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259•8870 pROJECT OVER 90 DAYS DUfiATION. <br /> II <br />