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� <br />Date�/�2�`L <br />Applica�ion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�� ,J _. A�,- <br />/►. <br />_ _ _ , <br />� <br />Pueiic Wo�es Pvrmn • 'Y � � � �` <br />mae 000�.• � <br />P�,�,�,�Wo,�,F�o 5 <br />ro�ri r�. <br />ioss nnn� re� ra�e S <br />eai,�w o�e 5 /�U <br />C] rY��- <br />qppticant Mailing Adtlress City Zip Phone <br />Describe Proposed Work <br />� <br />Prolett Add ess lil known) <br />Attach four (4) copies of plans lor proposed worh - D�aw to scale and note Ihe lollowing as applicable: <br />• Properly Lines � • Centerline of street <br />• Outtine and dimensions of all existing and • Ind�cate North <br />proposed sirucWres on the lot • Show �ny proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. AI� cells 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 ot Everett Design and Consiruction <br />Standards and Specifications. <br />3. Catl Location Undorground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•500-424•5555. <br />�� i�i'�L�CPNI :i'All. �,i'(,Lr\�,.0 SI�L `CUC�C- iu U'� �VC �L����N�71ft.(. <br />�tiC.A� ��LLI�I ✓iiC-121�/7CL!.. <br />. ��i�rCICrWT `_ rli1C�- rNt/i!(.L : _�,I,� ., `-7c I(.7C. <br />(�. :1?�(_icrt,.;� <r1�1�C, ; rJvC _ C<Ku��: i�,r2/i ''� -� <br />�� vv � i, �-c �, -;��C , ,r:�-i�s..l�rnl, <br />-�c ,,�Pfl��e --�' i �r �"-0 <br />Appioved lor Cons�ruction Date <br />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone:259�8010 <br />'v. �'� �� /Z <br />W <br />H <br />� <br />� <br />� <br />O <br />ACKNOWLEDGC-MENT OF GONDITIONS <br />The undersigned owner/applican� hereby agrees to hold and save harm- <br />less the Cily ot Evere�t Irom any and all claims lor damages, cosis. <br />expenses, or causes ol action that may arise because ol installation <br />and maintenance ol the Improvement or other rigM�ol-way use hereto <br />applied for and lurther agrees to remove same upon notice irom �he <br />City and to replace public properry damaged ihereby. <br />/, p <br />Date lA�. �! e -! �i� �L'��lCl .5 ' Z � ' / v <br />SignaWre ol Applicant � .j Da�e <br />WORK AUTHORIZED BY THIS P�'RMIT MUS�I BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED ANt) THEREAFTER IS TO <br />BE DILIG[NTLY PURSUED TO COMPLETION. THIS PERMIT M�Y B[ <br />CANGELIED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />