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j /� �,a S; � _ <br /> Date�z(¢�9) "`' Pubbc Worhe PmmO• �� �/ �` ''`` "" rr�� <br /> ApUlication For Bltlg.Dept�___�Q:��rp�p,� <br /> � -- v <br /> PUBLIC WORKS PERMIT rubTotelFnnFeO S <br /> �ass Appl.Fae PaiE S <br /> Balanceoua S <br /> Print or Type Only <br /> -�'d- � ,a�, 1-Jro� �S.3G-/rfA�e s:�= �=v��oJf ��z.o�- z��-.s3�9 <br /> Owner Mailing Address City Lp Phone <br /> _��t1,1 <br /> Applicant Mailing Address City Zip Phone <br /> DescribeProposedwork ��7 � C� "�A ��J��f/ <br /> /-� W <br /> Project Address(if known� `�S 3� /J•� �/e � � <br /> Attach four(4)copies of plans for proposed work• Draw to scale and note Ihe lollowing as applica6le: � <br /> • Property Lines • Centerline ol street � <br /> • Outline and dimensions of all existing and • Indicale North <br /> proposed structures on the lot • Show any proposed graAing changes <br /> • Existing and proposed utilities • Show measuremenis � <br /> �O NOT WRITE BELOW THIS LINE O <br /> PEiiMIT CONDITIONS <br /> 1.All calls for inspr.ction shall be made 24 hrs.in advance-phone 259-8870. � <br /> 2.All work shell be peAo�med in accordance with this permit and current City ol Everett Des!gn and Construction <br /> Stendards and Specifications. <br /> 3.Call Location Underground Service 4B hrs.before yau dig.TOLL FREE NUMBER 1-800-424-5555. � <br /> O <br /> ' �� h�i7 � �'-�'s ^ � <br /> �(J�'JL/L CJO�KS ��'/��..-�� � Y/ <br /> ��n O <br /> .j _ � � -`�/ a <br /> �CKNOWL[DGEMENT pF CONDITIONS <br /> The untlersi9ned owner/applicant hereby agr s to hold and save harm� <br /> -- less the City ot Everetl Irom any and all claims lor damages, cosis, <br /> expenses, or causes of action that may arise hecause of installation <br /> and maintenance of ihe improvement or other right�oFway use herelo <br /> applied lor and further agrees to remuve same upon notice irom the <br /> Approved lor Conslruction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTIGM Dale <br /> Approved as Consiru�:Ad Signature ol Applicant Date <br /> �At� PUBLICWORKSUE?AFlTMENT WORK AUTHORRED BY THIS PERMIT IdLi7 BE STARTED WITHIN <br /> 3200CedarStreet 180 DAYS OF �ATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA9B20t BE DILIGENTIY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLEO BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />