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Date��� � � <br /> PuDlie WorMa Perm�t• <br /> Application For eiea.o.o�.• c�CpCO�v <br /> + PUBLIC WORKS PERMIT '°°To,:FeeFee S <br /> � lesa npo�Fee Pa�a S <br /> Print or Type Only Beiancs Due S <br /> _� � �7yUa - /s� /.'i,co �'U A �1 �P��S� <br /> Owner MaiHng Adtlress City Lp Phone <br /> ��� �� <br /> Applicant Mailing Adtlress Cily Zip Phone <br /> Describe Proposed Work _ � � ��I� <br /> � <br /> Project Address(if known) — ��/ � <br /> Attach four(4)copies of plans lor proposetl work• Draw to scale and note the tollowing as applicable: � <br /> • Property Lines • Centerline of street � <br /> • Outline and dimensions of all existing and • Intlicate North <br /> proposetl structures on ihe lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremenis <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERMIT CONDITIONS O <br /> 1.All calls for Inspection shell be made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shall be peAormed in accordance with this permit and current City of Everett Design end Construction <br /> Standards and Specilications. <br /> 3.Cail Locatlon Underground Service 4B hra belore you dig.TOLL FREE NUMBER 1•800-424-5555. <br /> � <br /> �L�J"�i. Ct9�iL`+— /�2�...��f/�m/ KF�-Cr2'%tZ" O <br /> '//� ��/� <br /> ,'r ._'�. _y � V♦ <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/apDlicant hereby agrees to hold a�d save harm• <br /> less the City of Everett from any and all claims (or dai��ages, costs, <br /> expen5e5, or cau5e5 oi action that may arise beCause ol installati0n <br /> and maintenance of the improvement or other right-ol•way use hereto <br /> Approved for Construclion applied for and further agrees to remove same upon notice from ihe <br /> Date City and to replace public property damaged thereby. <br /> FINAI.INSPECTION Date <br /> Approvetl as Constructed Signature ol Applicant Date <br /> ev� PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 3200CeAarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everelt,WAg8201 BE DILIGENTLY PUFS�IED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259-8810 CANCELLED BY THE C�TV UPON ANY STOPPAGE OF WORK ON THIS <br /> -_ . - - c^ �� „ ..c ���.,.+ ...� <br />