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Date�"" ��? <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�'�11;E �. �kns�-orc� <br />Owner <br />� �, �. <br />AppGcaM <br />Describe Proposed Work �►, <br />�`13 0 F <br />ailing AdAress <br />Mailing Address <br />Cah1P)tl� <br />Zip <br />Zip <br />/ <br />PuOLc WO�ks Permit • 9� ���nh � <br />oiep oeoi • � <br />Prolecl AdAress (if known) <br />/p o� s �I `" f�-YQ U) L Y l � wa. <br />Attach bur (41 copies ot plans for propose�' work - Draw to scale and no�e Ihe tollowing as apUlicable� <br />• Property Lines <br />• Oulline and dimensions of aU existinp �nd <br />propased structures on lhe lot <br />• Exisling and proposed u�ilities <br />Pu4��c Worka Fee <br />Totc�Fre s <br />Less AOD� Fee PaiO S <br />Balance Duc s <br />3S= <br />onZ-3z�'-�G/�83/ <br />• Centerlir.e ol streel <br />• Indicate North <br />• Show any proposed grading changes <br />• Show mezsuremeNs <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be m2de 24 hrs. in advance • phone 259�8810. <br />2. All work shall be peAormed in accordance wieh ihis permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. betore you d;g. TOLL FREE NUMBER 1•800•424•5555. <br />� .Si�e ���0�•'� '�a fc C�nnC �-,r /��on G�/Jrnvcc� <br />' �� �.�,��Y% ��/iL;�� CJor.Es pi, //-/�-9� �p�� 4J�%achz.c�� <br />:-�� ' <br />/19y �� � l <br />Approved rConsiru ion ate <br />� /J/ ,c�+— J <br />f � <br />, �/ ��� <br />1NAL INSPECI"ION Dale <br />qppwved as Cons'ructed <br />����PUBLIC WORKS DEPARTtdENT <br />3200 Cetla� Streel <br />Everelt, WA 98201 <br />Phcne:259-8810 <br />AGKNOWL[DG[MENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />Thc unde�signed owneVaPplicaN hrreUy ag�ees �o hold and save harm� <br />less the Gty of Everett Irom any and all claims tor damages, costs. <br />expenses. or causes of action ihat may arise because ol installatlon <br />and maintenance of lhe improvemenl or olhcr righl-obway use hereto <br />;�pplied for and furlher agrees lo remove same upon notice Irom thu <br />City and to �eplace public property damag^d Ihereby. <br />� • <br />/ // I �% ' _ <br />� <br />Date <br />ign �1 re ol Applicant <br />WOFiK AUT�HORIZE Y THIS P RMIT T BE ARTED WITNIN <br />180 DAYS OF DAT PERMIT IS ISSUED AND THEREAFTER IS TO <br />8E DILIGENTLY PURSUED TO COMPLETION. THIS PEFtd1T MAY BE <br />GANCLLLED BV THE CITY UPON ANY STOPP�GE OF WORK ON THIS <br />PROJECT (�V[R 9� DAYS DURATION. <br />