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t'J �9i � <br />A7�x <br />9 Hx cn <br />y x i-�-f <br />MC C] <br />H xl <br />"�� H'�1 <br />CA H <br />�zr <br />� o� <br />OHd <br />��g <br />�� � <br />AH� <br />Y <br />t h+ H <br />�y <br />H <br />C] t7 fn <br />��� <br />yOt�i� <br />� Date � � ��lJ � <br />Application For <br />PI.BBL4C WORKS PERMIT <br />Print or Type Only <br />� (� <br />Owner Mailing AdJress <br />�ity <br />� InueiwwarvsPar � • <br />piag Ocpt + <br />PubLCWor45ie0 g <br />Totai Fee <br />Lass AODL Fee Pai4 S <br />B�IdnCO �UC 5 <br />Phone <br />Applicant Mailing Adtlress City 2iP Phune <br />Describ � Propased Work -1— I � � � �'�� '"'" I — <br />Project Address (if known) <br />Attach four (4) copies of plans lor proposetl work - Draw to scale antl note ihe following as applicable: <br />s Property Lines • Centerline ot street <br />• Outline and dimensions of all existing and O Indicate Norih <br />proposed siructures on the lot • Sho�v any proposed gratling changes <br />• Existing anA proposed u�ilities • Show measurements <br />PERMIT CONDITIONS <br />� 1. All calls for inspcction shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be pedormed in accordance with this permit and current Ciry of Ever�lt Des!qn and Constrc� tior <br />"' r► Standards and Specitications. <br />��. � 3.CaIILocationUndergroundService48hrs.beforeyoudig.TOLLFREENUMBER i-800•424•5555. <br />,_ _ <br />_a <br />,-- <br />... � <br />I ��j <br />9 @"j <br />� � � <br />-�/�� ��M �- �t�r � -�-�� <br />�,��v� �� <br />1�z�/9� <br />Approved lor Construction Date <br />FINAL INSPECTION Date <br />Approved as Conslructed <br />everett PUBLICWORKSDEPARTMENT <br />� 3200 Cetlar Streel <br />Everelt, WA 98201 <br />Phone:259�8810 <br />� <br />ACKNOWLEDGEMENT OF CON�ITIONS <br />W <br />� <br />� <br />Y/ <br />Z <br />O <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the Cily of Everett from any and all claims for tlamages, costs, <br />expenses, or causes of action ihat may arise because of installation <br />and mair.tenance of the improvement or other right-ot�way use hereto <br />applied lor and funher agrees to remove same upon notice Irom ihe <br />Ciry and to replace public property damaged thereby. <br />SignaWre ot Applicant Date <br />WORK AUTHORI'LED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIG[NTLY PURSUED TO COMPLETIOIJ. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON TH�S <br />PROJECT OVER 90 DAYS �URATION. <br />� <br />