Laserfiche WebLink
Date�_�L[_� S.1 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� , �l,> <br />i�,�m�4vm�.�❑�,m�i. ����' - _ <br />ome oeni . � � � S�_ <br />PUGLCWoikaFee g <br />Tolnl Fce <br />Lesa AO�� Fne PeiO 5 <br />Ll°,1�) OI. <br />�amncc0ue S <br />Ci,�„��, �L�,,r h1��1 N 3`i'" �;3C�Z Sr-u,�1le� ��d'/a3 Sy7-�z13 <br />Owner Mailing Address Ciry Zip Phone <br />App�icant <br />Describe ProposeC Work <br />Prolec� Address lil known) <br />City Zip <br />' - 3 =` /�.(: s_ �' <br />7_ <br />Fttach lour (4) copies ol plans lor proposed work - Draw to scale and note the following as applica�br <br />• Property Lines <br />• Outline and din �nsions ol all existing anA <br />proposed strucWres on the lot <br />• ExisUng an;1 proposed utilities <br />• Centertine ol street <br />! Indicate North <br />• Show any proposed 9radm9 r.hannes <br />• Show ineasurcments <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. In advance • phore 259•88� 0. <br />2. All work shall be pedormed in accordance wit'.i ihis perm'�t and current Ci�y ol Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. 6elore you dig. TOLL FREE NUiYIBER 1•800•424•5555. <br />;� �'r�L' C'i� i=,v": --� ���ct;'ti 1�Gii���= C"c-a'ST�'U[i����� <br />-� i� f� 70 9ck j''u.� 6� L,�,vr� /r�-7Tc=,e r�.�" N,F��� .9� n!!,t'B,�'0,«n,� <br />, <br />,;)f?PLiC:9NT S/%9LC f�= /f�S/�bNC//�Cf• fU,G' /�'fr'i�.�C%.C'_Ff'!/�C.En.,.it� <br />' ; ,:' <Jnl� l�7ni%C��� . <br />.. . �.��r: /7j._;-r. ,. ,1 ,— �� �,�. ,'l.-�� ,". <br />�//,� / <br />�1��' ��i •�'."_ �/,L��?5' <br />Approyed for Cons(ruClidn ate <br />YtNA��TtON�� ate <br />Approved as Constructed <br />rvcrMl PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, �VA 38201 <br />Phonc'.259�8810 <br />� <br />� �'/ r -. , . !�' � �. ' /' 4 � � <br />ACKNOWLEDG[MEN70FCONL �NS <br />W <br />r <br />!/ <br />Z <br />0 <br />� hr undwalqned owner/anplic�nl hereby agrees io hold and save harm� <br />luss thc G!y et Everelt Lom any and all c'aims for damages, costs. <br />expenses. or causes ol aclion Ihat may arise 6ecause of installation <br />and maintznance of Ihe improvement or other nght-obway use hereto <br />applietl �or and lurther agrees to remove same upon notice Irom the <br />City and to replace public property damaged ihereby. <br />> .-.=� �• �(�� �/z���� <br />Signalurc nf .4pplicant — at� <br />WORK AUTIIORIZED 8V THIS PERAIIT MUST BE STARTED WITHIN <br />180 DAYS OF DATF PERMIT IS ISSUED ANb THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION THIS PERMIT MAY BE <br />CANCELLED �V THE GTY UPON ANV STOPPAG[ OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION <br />