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Date��� ^ PuEI¢Warh6 Perml�� <br /> Application For emo oeo�.• �QL/ /7.�9 � <br /> PUBLIC WORKS PERMIT Pu01¢WorkaFea — <br /> Totei Fea s <br /> Lesb P00�Fee Pa10 S <br /> BdITtICC�UF S <br /> Print or Type Only <br /> �i,��r, n /�i���n�i //�/O/- ��p�,�o .5� .E✓P i A tf l.t�/�- ,/ri�i�ZlY�/ <br /> T Owner �MadingAtldress Cily Zip Phone <br /> �,���r- �n� /GC�S—s. Zn�crti� .r� sr��//P �,F��y 3a9-5�s > <br /> Applicant Mailin.3 A ress Cily Lp Phone <br /> Describe Propased Work _�.�T�!/� r�( 'Id��'� <br /> ProjectAddress(ifknown) /���� —a'tC �T-✓p ,r� _ /�/� � <br /> Attach lour(4)copies ot plans for proposed work- Draw to scale and note the following as applicable: � ��� <br /> • Property lines • Centerline ot street � <br /> • Outline aad dimensions of all ezisting and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Ezisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> t. All calls for inspection shall he made 24 hrs. in advance- phone 259•881 5. � <br /> 2. All work shall be pedormed in accordance with this permit acd current City of Everett Design and Consiruction <br /> Standerds and Specifice�ions. <br /> 3. Call Localion Untlerground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424•555$. � <br /> /l/C Pl/dC.e CJv,r.�s PF.Pin.T .QFqv,.C�".Q �/,�,e�d O <br /> / <br /> �� � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGE�SENT OF GONDITIONS <br /> The undersigned owner/applicant hereby agrees to holo and save harm- <br /> less the Ci�y of Everett Irom any and all claims lor tlamages, costs, <br /> eapenses, or causes ol action Ihat may arise because ol installation <br /> and maintenance ol Ihe improvement or other right�ot�way use hereto <br /> applied lor and further agrees lo remove same uFon nolice Irom the <br /> Approved lor Construction Date Cily and to replace public property damaged lhereby. <br /> FINAL INSPECTION Date <br /> A� proved as Consiructed Signatu�e ol Applicant Date <br /> everelt PUBLIC WORKS DEPARTMENT WOR:� AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION.THIS PEfiMli MAV BE <br /> Phone: 259�8815 CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PFOJECT OVER 90 DAVS Dt1RATION. <br />