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Date �����wo�ks P�,m��. �/F� — <br /> Application For B�ae o�P�.� " � /� - �a <br /> PUBLIC WORKS PERMIT PueTo�FeaFee s � <br /> Less AOPI.Poe Pni� $ � ,c� <br /> Oalance0ue g `L�� <br /> Print or Type Only <br /> R�,�J�I -r�_s� � rz n/n,.ti a;� .�,� F���r�� �v ���� <br /> Owner Mailing Address Cit?-� Phone <br /> �n M.� � �. <br /> Applicant Mailing Address City Lp Phone <br /> tlascribeProPosedWork �Pl1/ Sir��� ��-IVII/cf /CV/� L„ ` �6'� �� Z �. . . <br /> W <br /> ProlectAddresslitknown) � 3�z" y Z'"�� �Z' SC � <br /> Attach four(4)copies ol plans lor proposed worh- Draw to scale and note Ihe following as applicable: � <br /> • Aroparty Lines • Centerline ot street � <br /> • Outline and dimensions ol all existing and • Indicate North <br /> proposed structures on the lot • Show any proposed gradinc�chanc�es <br /> s Ezisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERMIT CONDITIONS <br /> 1.All cells tor im.�pection shall be mede 24 hrs.in ativance-phone 259•8810. � <br /> 2.All work shall ae pedormed in accordance witP this permit and current City ol Everelt Design and Construction <br /> 3tandards ano Specificalions. <br /> 3.Call Location UnJ�rground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-500•424•5555. � <br /> 4.ANY CHAt�GE IN THR DRIVEWAY CUT MUST BF. P. .PPR011ED O <br /> SY THF. PUBLIC WO:dKR 1NSPECTOR. <br /> 5.l'.ONNECT DOWNSPOU;'.S TO PUBLIC DRAIidAGE SYSTEN.. � <br /> 6.KF:EP CTTY STREETS CL�EAN AT ALL TIMES_ <br /> 7.ANY DAMAGFs TO THE CURB AND SIDfiWALK WILL BE REPA1RF:ll � <br /> TO THE SATISFACTION OF THE PUBLIC WORKS DEPT_ O <br /> a <br /> �� <br /> � ACKNOWLEDGEMt : OFCONDITIONS <br /> � � The undersigned o�,��n=dapplicant hereby agrees to hold and save harm� <br /> a less Ihe City ef �. .�.:tt Irom any and all claims tor damages, cosis. <br /> expenses, or wuse�: ot action Ihat may arise because of installation <br /> �L �C� �_z9�g 1 and maintenance cl Ihe improvement or other right-of�way uae hereto <br /> U applied lor and further agrees to remove same upon nolice Irom ihe <br /> Approved for Con tr tion ` ���e Ciry and to replace public pro erty damaged Ihereby. <br /> ���-l-l'��� f /�'� � � <br /> � . , <br /> FINAL INSP ION Date � � - � - <br /> Approved as Construcled Si naWr of App icant a�e <br /> everett PUBLIC WORKS DEPARTMENT WORK UTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 180 DAVS OF DATE PEPMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BC- <br /> 1 Everelt,WA 98201 CANCHLLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> � Phone:259�B81U PROJECT OVER 90 DAYS DURATIQN. <br />