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Date�J�'�..�,1' <br />Application For <br />PUBLIG WORKS PERMIT <br />Print or Type Only <br />v r'r vf a rc�t �� <br />Owner <br />�Q tM `� <br />qpplic�nl <br />Describe Proposed Work <br />Prol�ct Adtlres5lil know'n) <br />ly ,N.347" A <br />Mailing Addre�s <br />_ � 'rd <br />Gily <br />�r� /7S <br />P�.Iiim WmksPo�mit • p�� . <br />�ia9 nen� + � l—/� -- <br />Pu1�i�c Woihs Fee S <br />ioint icc <br />Less AOP� Fee Pa�� S�_ <br />e,i.�« o�� s � � � <br />'1L2 JY / — a G/ - <br />Zip Phone <br />Zip Phone <br />Attach lour (4) copies ol plans lor proposed work - Drew to scale and note the followmc� as applicable: <br />• Properly Lines <br />• Outline and dimensions ol rll ezlsting anA <br />proposetl Slruciures on Ihe lot <br />• ExiSting ani proposecl u�ilitics <br />TE <br />• Cenlerline ol Slree� <br />• Indita�e Nor�h <br />• Show 3ny proposed gradlnc� char�es <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pertormed in acwrdance with ihis permi� and curren' City ol Everetl Desiqn and Consiruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. befon; you dig. TOLL FREE NUMBER 1-800•424-5555. <br />1.AI'dY CFIAIVGC IIV TI;E DF'"[VEWAY f:UT I"�118T E:�- �1FF'F.OI;.^f, <br />P1' TI-IE' F-`UFL_ I C Wi �RYS l'1=F'AFTMI=:IV 1. <br />S. USE FUFLIC DF��1I�IAG!= �1'STF_M AS f'r�f 1:[iEL I n�, i l i i�l �' i i: . <br />�, AN1' I DT GRADE CNAIVGf.B MUST EE AFFFOVI_,. !: '.,_ <br />F'IJE�I_[C I�IOFI<'S I�I5FFCTOFi, <br />.P:F�fF Ci''V' . I �;1�;=1�._ �.-7J=!1hl �',l „-I. �!"If1E5. <br />/ <br />,,.� f�%1�s-o-.Gi y .'d� 8B <br />Appic,ved for Co struction Date <br />�, <br />��i� ,��� <br />INAL INSPECTIO � —T ali <br />Approved as Constructed <br />everrtl PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Stre!t <br />Everett, WA 992G1 <br />Phonc'. 259�BE310 <br />�CKNOWLEDGEMENTOFCONDI�.�ONS <br />W <br />� <br />N <br />i� <br />O <br />7he unAersigneJ owner/applicant hereby a9rees to hold and s�ve hann� <br />less ihe City ot [vernll irom any and all claims for daronc�es, costs. <br />ezpenses. or causes ol ac�ion that may arise Uecause o� installation <br />and maintenance of the Improvemenl or other nc�hbol-way use hemto <br />applied lor and furihe� agreas to remove same upon nolice Irom Ihe <br />Cit nA to replace pu6lic pi^uerry dama9ed Ihereby. <br />�—� �d ���� ��3%� <br />Signature of ApPlicant � �e�e <br />WORK AUTHORI7.[D BY THIS PERMIT MUST BE STARTFD WITH!N <br />180 DAYS OF DATE PERMIT IS ISSUED AIJD THER[AFTER IS TO <br />BE DILIGENTLY PURSU[D TO COMPLFTION. THIS PERMIT M11�Y BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJ-�T OVLR J� DAiS DUR�TION. <br />