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Dat� . �e - S 3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />��, c�, P � <br />Mailing Address <br />��� 1 � I� J 1'; <br />� C <br />�/Z 5 � °`�/� ��- <br />( / � �I�� <br />7� <br />Pu�Lc Works Permit • �� � <br />emg. ono�� � <br />Pu�bc Works Fee g � <br />To1al �ee <br />Less App'. Foe Pela S_ <br />BdI811C'! ri11P J <br />, ��, � <br />� Z 5�i, -� <br />Phone / <br />Applicant Mailing Address Gity Zip Phon6+ / - <br />Froiect Address (if known) <br />Attach (our (4) copies of plans lor proposed work - Oraw to scale und nole Ihe fcllowing as applicat�'e: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed siruclures on the lol • Show any proposed grading changes <br />• Eaisting and proposed utilifies • Show measurements <br />PERMIT CONDITIONS <br />1. All calls lo� inspection shall be made 24 hrs. in advance � phone Z59�8$� S. <br />2. All work shall be performed in accordance with ihis permit and current City of Everet� Design and Construction <br />Standards and Specifir,ations. <br />3. Call Location Underground Servic._ qg hrs. betore you dig. TOLL FREE NUMBER 1-800•424-5555. <br />/. 1['fh..� 11 �O� (O� �1GQ.Y IH� u.+I � NO �taL\Nu[�IOr� (� <br />l'XGau.+�t'.J.. ��or �roP05..,.0 �J��ci� �) �. �oC �c:r�(c�C � <br />1 (� <br />$. �tc\S�'Ih` �..rre.n...i�.n` S�c�aw.�1�9 ctfG he�'�O �t� rL'w..ove<x <br />tl J <br />i <br />�i'�,��1/�,�' ,�-,�,� <br />Approv�Consiruction j' - D�te <br />�/ / <br />� � / ' j/ , <br />�, �% '�:C. ? �' �/�'�—��� <br />F1NAL'INSPECTION Dale <br />Approved as ConsVucted <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Streat <br />Everr.tt. WA 98207 <br />Phone� 259-8815 <br />ACKNOWLEDGEMENT UF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />7he unde�, :igned owner/applicant hereby 2grecs to hold and save harm� <br />less the Ciry ol Eve�ett Irom any and all claims lor damages, cosis, <br />expenses, or causes of action that may arise because ol inslallatioi� <br />and maintenance ot the improvement or other ric�M�of-way use hereto <br />applied for and luriher agrees to remove same upon noliCe irom lhe <br />City antl to replace pu6lic property dama,qed thereby. <br />r / /� <br />l� 7�l � <br />f." � /�i <br />Sig ure of AppliCant Da e J <br />WO K AU7HORIZED BV THIS PERMII MUST BE STAf.�ED WITHIN <br />180 DAYS OF DAT[ FERMIT IS ISSU=D AND THEREAF7ER IS TO <br />BE UIUGElVTLY PURSUED TG COMPLETION. THIS PEFiMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE JF WORK ON THIS <br />PROJECT OVER P� DAYS DURA710N. <br />H 1- <br />y �. <br />H �- <br />U7 "- <br />J C <br />�] �. <br />�� <br />�� <br />� <br />�� <br />�k <br />rya � <br />K� <br />O Y� <br />�E <br />F <br />o rr, <br />( l ' <br />�� <br />r <br />y '' <br />