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Date 3//f��F>'S <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�'/c� <br />Applicant <br />Project Address (il known) <br />6.'. <br />Mailing <br />ity <br />PuO��c WorASPeim�t • <�'S- G 3' <br />8�00 Deo�� • <br />PuO�rc Works Fee <br />Toial Fae S <br />Lefa Aoo� Fee Paip S <br />Daienca0ue S1-C Cf/.4.e'lrE� <br />�.3`l /G �, <br />Phone D� <br />J.�y�t,,�.c„c�sc�-, � <br />!ip YhonC <br />�/� /, � �'�'� �� _F- ��/ L'_/ � � % <br />n u [i.^ �, i CP�n �^� 7 C� ��7 2� <br />�/„ �<<.l,! ///.-.�., ��/ !�/. M.��,:,c L �. c,.i D/�. ;.e �> �_ //�•«. <br />�it� l�X: � 7 AP i��/.� �i» �o i �..,c✓ P.f {v/ L✓ i�'1i/�nn L/,vo_i /�i r� <br />��� <br />Atlach lour (4) copies ol plans �or proposed wak - Draw to scale and note ihe following as applicable� <br />• Property �ines <br />• Ou�line and dimensions ol all existing and <br />proposed structures on Ihe lo� <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />a Genterline of street <br />• Indicate Norih <br />• Show any proposed grading chan�es <br />• Show measurements <br />LI <br />1. All calls for inspectior shall be made 24 hrs. in advance • phone 259-gg15. <br />2. All H�ork shall be perlormed in accordance wilh �his permd anA current City ol Evere�t Design and Consiruction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMdER 1-800•424•5555. <br />��. Si C�-l'S ��� �.I�CL� <br />��Gi�"�` `L ��'�I-.C'�,'�L�� ���L��� <br />-P� ��r�cc-n��. �����'T _ <br />??" <br />�lpprovcA lor Construction Date <br />� / <br />l� /�l' .�� - 2'o t�,.�=��-� <br />FIIJrtt—�HSPE6i1LlN) �—� Date <br />4varov� .��� �T�^�*+�d <br />everru PUBLIC WORKS DEPAR7MENT <br />� � 200 Ceda� Street <br />�:eret�. lV� 9i3201 <br />Phonc�259 8815 <br />��-�-- ���� <br />ACKNOWLEDGEMENT OF GONDITIONS <br />W <br />H <br />_ / <br />� <br />� <br />h <br />� <br />O <br />a <br />The undersic�ned owner/applicant hereby agrees to hold and save harm� <br />less ihe City ot Eveiett Irom any and all claims lor damages. costs, <br />expenses, or causes of action Ihat may arise because ol installalion <br />�nd mainlenance of ihe improvement or other �ight-ol-way use hereto <br />�applied for and lurther agrees lo remove same upon notice Irom lhe <br />City and to replace puU c properry damaged thereby. <br />1 .� .g.-�I't- J � J�C''� <br />�Si at�re ol Applic nt Date <br />RK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 D.4YS OF DATE PEHMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILICENTLV PURSUED TO C011PL[TION. THIS PERM1;IT MAY 0G <br />i..NC[1 LCn [31' TH� C1T1' UPO ' 1�'r STOPPP,GF OP WORK ON THIS <br />I fiJJLC 1 UVEf� li0 f� i1 F DUf': � ION <br />�; <br />r. <br />z <br />