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Date�.?'—�L' v�no�wo�ksra,mn. !2 /O <br /> Application For eiay oeo�.• <br /> PUBLIC WORKS PERMIT PubTolaFeeFee s <br /> i.ess Appl.Fea Pe�a $ <br /> no <br /> Balance Dua S ���� <br /> Print or Type Only <br /> 002 - 3 r'� Y o%a">'/ <br /> �i� � I��r I ic.» d�/�-3�I�lt= C�v-,�(— ) d.,z r� �3S_3 3� 2 Z <br /> Owner Mailing Address City Zip Phone <br /> 5�1 r�-2 <br /> � , � Applicant Mailing Address Ciry Zip Phone <br /> /�� �pA i� <br /> . Describe Proposed Work �y,?�9�1a(L.�+ � �'� p,�u.�'v"` �YV'l� ��'t � -�`3 ��� , <br /> �- o BaaZ �� � . 5� <br /> W <br /> Projed Address(il known� � <br /> Attach four(4) copies oi plans lor proposed work• Draw to scale and note Ihe following as applicable: � <br /> • Property Lines • Centerline of sireet � ' <br /> • OuUina and dimensions ol all existing and • Indicate North <br /> proposed structures on Ihr lot • Show any proposetl gratling changes <br /> • Existing and proposed utili�ies • Show measuremenis � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMI'i CONDITIONS <br /> 1.All cslls for inspection shall be made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shall be pedormed in accortlance with this permit and current City ol Everett Design and Construction <br /> Stanrtards and Specifications. <br /> 3.Cail Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> /• �c,c?� C! J�f/ Sfr.:�7�' CCe'rli) �Z� �i�� 'fin��S , O <br /> � <br /> � <br /> O/� <br /> 1� <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/appbcant hereby agrees to hold and save harm- <br /> less the Gity of Everetl Irom any and all claims lor damages, costs. <br /> expenses. or causes of action ihat may arise because ot inslallation <br /> l/� �' ` �/e and mainlenanca ol ihe improvement or olher righbol-way use hereto <br /> �� �r� 'Y'' �Z applied lor and lurlher agrees !o remove same upon notice irom ihe <br /> Approved I nstruction 7 �a�e Ci�y and to replace public properry damaged Iheieby. <br /> � �_ �_n �3 !1 � <br /> n i � <br /> FIN INSPECTI �« � <br /> Approved as Consiructed Sigri�ature ol Applicant Date <br /> �Ar� PUBLIC WORKSDEPARTMENT WORK AUTHORIZED BY TIiIS PERMIT MUST BE STARTED WITHIN <br /> 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br /> Everelt,WA 98201 BE DILIGENTIV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> CANCELLED BY THE CITV UPON ANY STOPPAGE OF WOFiK ON THIS <br /> Phone:259-8810 pROJECT OVER 90 DAYS DURATION. <br />