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il <br /> Date��� Pu01ic WOiks Parmit• � � <br /> BICp.Dept.y <br /> Application For <br /> PUBLIC WORKS PERMIT PubToteFee�ee S �� `— <br /> � <br /> . �ess noot Fee aa�a S ^�d <br /> � <br /> Balance Duu $ <br /> Print or Type Only <br /> �w�lz�iPi9.�i� /.� 3 �����sy L�1/ 9��v� zS�- �iL 3 <br /> Owner Mailing Address City Zip Phone <br /> �R�'�- <br /> Applicant Mailing Address City 2ip Phone <br /> Describe Proposed Work `��e�� ��� � " l�J � <br /> � <br /> W <br /> Prolect Address(if known) _-l��-� - a 3 -- � <br /> Attach(our(4)copies of plane(or proposed work• Draw to scale and note the following as applicable: � <br /> • Properry Lines • Centerline of slreet � <br /> • Outline and dimer.sions of all existing end • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERNIT CONDITIONS <br /> 1. All calls for inspection shall be mede 24 hrs. in advance• phone 259•681 5. � <br /> 2. All work shall be performed in accordance with this permit and current City of Everett Jesign and Construction <br /> Standerds and Specifications. � <br /> 3. Call Location Underground Service 40 hrs. before you dig.TOLL FREE NUMBER 1-800•424•5555. <br /> y�- ���,�y ��-���T� � ,�r- O <br /> S. ��F'��„��is y�����,✓�- a� �'�c��� � <br /> c�i�c �'�C 7c�i.� �'Fi�iSt,/� O <br /> \ <br /> a <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/appli:ant hereby agrees to hold and save harm- <br /> , Iess the City of Everett from any and all claims lor damages, costs, <br /> expenses, or causes o( action that may arise because ol installation <br /> and maintenance o� the improvement or other right•of�way use hereto <br /> e^� � � applied for and lurther agrees to remove same upon notice Irom the <br /> Ap ved fo Const tion Date City and lo replace public property damaged thereby. <br /> ���.�.(��'..��s=/- � . ,/1,G,�i -.�7�� <br /> FIN INSPECTION Date Date <br /> Approved as Constructed Signature ol Applic t <br /> WORI< AUTHORI ED BY THIS PERPdIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENT�Y PURSUEU TO COMPLETION.THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLFD BY THE CITY UPON ANY S70PPAGE OF WORK ON THIS � <br /> Phone: 259-8815 PROJECT OVER 90 DAYS DURATION. <br /> i -- <br /> � <br />