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Date_�'� <br />Application For <br />PUBLIr WORK� PERMIT <br />Print or Ty�e Only <br />�R <br />f, �plicant <br />Describe Proposed Work <br />Project Atldress (il known) <br />� <br />Mailing Address <br />P�o�,�,-,o,,, ���,mp, . j�-8P -/7 9— <br />Bmp oco�. • _1L��—/—t�— <br />i <br />Pubi¢WorFnPee $ <br />Tolxl Fee <br />Less ApPI Fec Pnra $ �� <br />Balancc �uc $ <br />SPC,�le. 7�'((%� 5`f%- <br />Ciry zip <br />Ciiy Zip <br />— Lo f .aaw i„�,.,e /�a.✓n�n <br />Altach lour I4) copies of plans lor proposed work � Draw lo scale and note Ihe tollowing as applicable: <br />• Property Lines • Centerline ol sireel <br />• Outline acd dimensions ol all eaisting and • Indicate North <br />proposed structures on the lot • Show any proposed yradin9 changes <br />• Existinq and proposed utilities • Snow measuremen!s <br />ne <br />Phone <br />PERMIT CONDITIONS <br />1. All cails for inspection shall be made 24 hrs. in advance � phone 259$810. <br />2. All work shall be pertormed in accordance wilh �his permit and wrtent City ol Everetl Desiyn anC Construction <br />Stendards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-500•424-5555. <br />4.��PI1' C'Iit"If]C.: l.fd TI-iC i:f(T.VLWr^�'r C!�T iil.I.�T ��f_' �f �f`.ti'.'t:-:D <br />lil' TIiE F'VPLiC P!U;:t:S DEPA(tTt'iC:i�IT. <br />�.USE fU6LIC DRAINA6[ Sti'STEI°I AS F'F:fi� IiEt c(i�i � ;�.f'-. <br />�,.ANY LOT r,RA6�: CI-IAiJf•I'B I'nUS:I �;F_ 61h'i FCiV! 7'� �i-_: <br />I��I _' ( li ._ t, r .,. l�'. <br />� � �. '��.i i i ���i i � .��I .. � ��i .I i i I ��. . <br />�GF.� �o�'� S��G�BB <br />Approv for Consiruction ate <br />/` /�/ , <br />�L / �� �C�(- �/� tr"� '� �:i�l <br />FINAL INSPECTION � Date <br />�pproved as Constructed <br />rverett PUBLIC WORKS DEPARTMENT <br />� 320U Cedar Street <br />Everell, WA 98201 <br />Phone:259�6810 <br />/ <br />� <br />O <br />� <br />N <br />O <br />a <br />�CIWOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereUy ac�rees to h�id and save harm- <br />less Ihe City ol Everell Irom any and all claims lor damages, costa, <br />ezpenses. or causes of action Ihal may arise because ol installa�ion <br />and maintenance of ihe improvement or other right-ot�way i�se herate <br />applied tor and lurther agrees lo remove same upon nutice Irom the <br />Cit and to replace public 4-operty damaged thereby. <br />( -,._„� � nr��� ��/d'.�l -- <br />Signalure ol Applicant � � �a� � <br />WORK AUTIIORIZED BY iHIS PEFMIT MU�T BE STAFTEU \NITIiIN <br />160 OAYS OF DATE PERMIT IS ISSUED AI�D THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERA'�IT MAY B[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOFI< (�N THIS <br />PROJECT OVER 90 DAYS DURATION, <br />