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Date_L�,/jCF�L � PUUt¢Worhs Pcrmit+ v /� � <br /> � � BIEp.DepL• <br /> Application For <br /> PUBLIC WORKS PERMIT PueTollFeeFee S <br /> Less ApO�Fae PaiG S <br /> Belunce Uua S <br /> Print or Type Only ' � <br /> G�v' �/Z.C��G��('{' "'�i ���� � ��L �G�� �S J- �l�✓ <br /> Owner Mailing Address f:ity Zip Phone <br /> !S1�' / �t.�,� � �/ <br /> Applicant Mailing Address City Zip Phone <br /> Descri� Proposed Work �-`' "" <br /> . <br /> � � <br /> W <br /> Pro}ect Address(if known) ,O � <br /> Attech lour(4) copies of plans for proposed work• Draw to scale and note the following as applicable: � <br /> • Property Lines . • Centerline of sireet � <br /> • Outline and dimensions of all existing and • 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 O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspeclion shell be ma.:e 24 hrs. in advance•phone 259•8815. � <br /> 2. All work shall be performed in accordance with this permit and current City of Everett Desiqn and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-SOO•424•5555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owne�/applicant hereby agrees to hold and save harm• <br /> less the City of Everett irom any and ali claims for damages, costs, <br /> expenses, or caus�s of action that may arise because of instaltation <br /> �n✓ �LyS� � � and maintenance of the impwvement or other right�ol�way use hereto <br /> a{,plied lor and luriher agrees lo remove same upon notice irom the <br /> Approved for Construct on a�e City and to replace public property damaged thereby. <br /> "_�/���,.��` �-�j " C/�f'/. <br /> FIN INSPECTION Date � <br /> Aoproved as Constructed :;igna ur �oi A fcant Dale <br /> PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STA ED WITHIN <br /> everett 180 DAYS OF DATE PERMIT IS ISSUED AND THERE FTER IS TO <br /> � �200 Cedar Slreet BE DIIIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everelt,WA 98201 CANCELLED BY THE CITY UPON ANY S70PPAGE OF WORK ON THIS <br /> Phone: 259-�P3 gsVp pROJECT UVER�0 DAYS DURATION. <br />