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Date ���/ <br />qpplication For <br />PU�LIC VIIORKS PERMIT <br />Print or Type Only <br />APP�icant <br />Descnbe ProDosed Work <br />Adtlress <br />�5�� �.3c; <br />Mailing Atltlress <br />Po01¢ Nb�Ff Perm�l • ��� � - <br />. �i' � <br />Bitly �e0� � V i� _ _ <br />PuoLCWo�xafee s ���_� <br />To�aiFee <br />� <br />LelSApu� FeuPaid $ _ <br />C <br />Paiance Dux S I� � <br />�� <br />` �/„2/ .3.1s- 1Ss.3 <br />Prolect Address (if knowN _+ �' ?� c t L` c"�t'� � 7�O �. ����'�/�'G <br />Attach lour (4) copies ol plans lor proposed work - Draw ro scale and note the 'ollowing as applicable: <br />• Properry Lines • Conterhne o'street <br />• Outline and dimensions ol all existing and • Inc'icate North <br />proposed sVucWres onihelot • Shcw ar.y proposed grading c�anges <br />• Ezrsting ;:nd proposed utilities • Show measurements <br />PtRM1T CONDIiIONS <br />1. All ealls �or mspretion snall be made 24 hrs. �n ativance - phone 259•881 5. <br />2, All work shall be perlormed m accoiaance with ihis oermd and current Cdy ef Everett Design and Construchon <br />Slandards and Spec;licat�ons. <br />3. Call Location Undergrountl Serv�cr. ntl hrs. befcre you dio. TOLL FREE NUMBER 1•800•424-5555. <br />� ,o�-.e .��3��o i�.�l��Js <br />,_ -,.. _,�� <br />J " <br />FINAL INSPECTION <br />Approved as ConsVucte� <br />i <br />Gi4 `"—' �td'. i'- 1 <br />Date <br />PU6lIC WORKS DLPARTMENT <br />3200 Cedar Street <br />Evereu. 1'JA 91i20+. <br />rnone�7g9�GH15 <br />v��-�� � <br />uTj<�Ticc^"1 <br />W <br />� <br />� <br />� <br />Z <br />0 <br />ACKNOWLEDGEh1ENT OF CONDITIONS <br />The undersiyned ownerlappticant hereby agrees to hold antl save narm� <br />ICss Ihe City ot Everett Irom any antl all claims lor dama9es. Cosis. <br />erpenses. or causes ol action that may anse because of ir.stallation <br />and maintenance of the improvemcnt or other nght�ohway u::e neirto <br />applied lor and lur�her agrees to remove same upon notice from �hr. <br />Ciry and lo reUlace pubhc property aamagetl thereby. <br />oiyiia��io .,...Y�. <br />WORK i+UTHORI -D BY TNIS PEflNIT PdUST BE STARTEO WITHIN <br />180 DAYS OF DATE PERh11T :S ISSUED AND THEflEAFTER IS T'> <br />BE DIUGENTLY PUFSUED TO COMPIETION THIS PEFPlII '.tA�' -'°. <br />CANC[LL[D 6Y THG CITY UPQN ANY STOPPAGE OFPJnRK GN "�iS <br />�'ROJ[CT OVER FO DAl'S DUF�TiON <br />� <br />� <br />� <br />