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Date� � �O <br />Application For <br />PiJBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Describe Proposed Work <br />W <br />PuElic WoiMe Permit • `�' • �p/; <br />Bieg. Deo� • � n � / % S-f—li— <br />Pu�Lc M.orkf Fea S <br />Total Fon <br />Less PDG�- Fee Paid S �O -a <br />Balenca Duo � <br />� <br />projecl Address (il known) <br />/08�5— 'f'=' A✓E SE <br />Attach lour (al copies ol plans lor pr000sed work - Draw �o scale and note� Cen�erline ol s�PeQi1 able: <br />i F'roper�y Lines • Indicate Nor�h <br />• Outline and dimensions ol all exisling and � Show any proposed 9rading changes <br />proposed slnictures on thc lot � Show measurements <br />• Existing and proposed utilities <br />B�s-a3n� <br />� <br />rnvnc <br />PERMIT CONDITIONS <br />7. All calls for inspection shall be made 2A hrs. in advance - phone 259-88i 5. <br />2. All work shall 6e perlormed in accordance with Ihis permit and current Cily of Everelt Design and Construclion <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NJMBER �-800•424-55$5. <br />h� S/OEcvNL.t� CU�zB t GuT7�� 9,e6 ,N6al � �GNb',Pa,tEnl. <br />�R/f/ �<Jrn9� T1J TNEM cSf/�9GG /3_r ,(�EPc qcE� �f/ <br />THE' 9�r��:��'.�T, <br />S, .�J�y CD�G�f'EYE WD.c.0 Si/�9LL ,BE ,r.tJSr�CCT.�-u <br />/',Zio,e To P�X/,e�N�r� <br />�o, IitJ 5'i rS'L C l�,Py�JEL GS .�,e .1>aulir/-si'o!/75 TO T/E S.JTo <br />.�4.G�ro�� /���1 <br />Approved n truction Date <br />t C�. �� _ a� <br />_ ( <br />FINAIIN PECTION Da <br />Approved as Conslructed <br />���,���� PUBLIC WORKS DEPARTMENT <br />� �2n0 Cedar Streel <br />Everett. WA 9D201 <br />Phone:259•BB15 <br />ACKNO�NLE�GEMENT OF CONDITIONS <br />W <br />H <br />� <br />C;' !1 <br />� <br />O <br />�r� <br />V♦ <br />O <br />a <br />The undersigned owner/applicant hereby ac�rees to hold and save 1`arm- <br />less the City ol Everetl irom any and all claims for damages, costs, <br />expenses, or causes of action that may arise because ol installalion <br />and maintenance ot ihe improvemehnt or other right-ol-way use hereto <br />applied for an I rthe� agrees t r move same upon notice irom the <br />Ciry and to re ac publi�oper y�amaged lhereby. <br />Signat of Applicant Date <br />WOR AUJM�ORIZED BY THIS PERMIT MUST BE STARTED WITHI�J <br />7g0 9Y5 OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLFD BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECi OVER 90 D�YS DURATION. <br />