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S 1, 3/30 0 <br /> Date ` Public Works Permit <br /> Application For Bldg.Dept.# :, .. � <br /> PUBLIC WORKS PERMIT n~ Public Works Fed <br /> h Total Fee 41, _ _, f <br /> Less Appl.Fee Paid$ <br /> Print orType Only ft t3O1! : Balance Due $ 6.7-• = <br /> ✓'7a r,, v e22 322VO/5l63/ <br /> Ai <br /> /� � Rim <br /> Ai PRf`Lad -Do i 4 ^ <br /> w A5 1.332 Giej/ / e JqZ 02., -Oct,. <br /> / <br /> Owner Mailing Address City a Zip Phone <br /> �l`'tiii <br /> izt.h. ? <br /> Applicant Mailing Address City / Zip Phone , <br /> r <br /> Describe Proposed Work lie/ f 1 a f ei,K°/ eat i/3 ?2;id / 2. ti /4 <br /> 1: /4 <br /> A4 <br /> ‘1' 1 =1111111MINI <br /> Project Address(if known) . 1..1111 <br /> Attach four(4) copies of plans for proposed work- Draw to scale and note the following as applicable: 11.111111 <br /> • Property Lines t • Centerline of street <br /> • Outline and dimensions of all existing and • Indicate North Cn. <br /> proposed structures on the lot • Show any proposed grading changes , <br /> • Existing and proposed utilities • Show measurements <br /> Ca <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS ,,,,, <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259-8810. <br /> 2.All work shall be performed 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 1-800-424-555S <br /> ',, ' *.,, , . . 0 <br /> .?: CO <br /> 0 <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everett from any and all claims for damages, costs, <br /> s� expenses, or causes of action that may arise because of installation <br /> ' c? -^ Oft- <br /> � and maintenance of the improvement or other right-of-way use hereto <br /> °� applied for and further agrees to remove same upon notice from the <br /> Approved for Constr ction te City and to replace public property damaged thereby. <br /> de <br /> FINAL INSPECTION Date / G,� ..�"" <br /> /-112--,--1—.. 7--- - q 3 <br /> Approved as Constructed ure of Ap Ilcant\f Date <br /> WORKS DEPARTMENT WO K AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> PUBLICWORKeet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA9tree8201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8810 .-- ,,. PROJECT OVER 90 DAYS DURATION. <br />