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Date��s— <br />� Application For <br />Pl.'BLIC WORKS PERMIT <br />Prn! or Type Only <br />Owner <br />Address <br />PuOf¢ Woike Germ�it • � ��i v <br />eiao� Doo�. • <br />Po�f¢WorbFea aO f� <br />Talal Fea s <br />LessAOPI Fee Paid S� <br />BalenceDoe S ���v= <br />T1'`�j� /d-�= . <br />Phone <br />� ��i�- <br />_ 3�- �3�6 <br />Applicant Mailing Address City 2ip Phone <br />Describe Proposed Work � s/�%Qt� i��/�jL� �7v����� <br />Prole :1 Address (if known) <br />� <br />4ttach lour (4) cupies ol plans lor proposed work • Draw to scale and note Ihe lollr,win 3 as applicable: <br />• Properq� Lines • Centerli�ie of street <br />• Outline and dimensions of all exisling and • Indi.ate Norih <br />proposed sVuctures o�� �he lot o Show any proposed grading changes <br />• Exisling and proposed utiii;!�s • Show measurements <br />PERMIT CONDITIONS <br />t. All cails for inspection shall Ue maae 24 hrs. in aovance - phone 259•881 5. <br />2. All work shall be pertormed in accordance with this permit and current Ciry of EvereQ Design and Consiruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. betore you dig. TOLL FREE NUMBER 1•800•424-5555. <br />`f, %ff.�s ��T c.2'-=r"c�laS d/t7 f� �//-T S�9T/v /l� <br />�-.�� .S:j�N/7�/'` �sc-�s� ��'�diC� Tir� <br />�� h�iSZ1' y�T /f�'c��e� i/�-- .C/FT s'Ti9Tlv� <br />� ,P_ o/��i9 ��� � ?� ��i'in.� .T 7�S' o/`f 7-/`iS J-�i�, <br />O ��c!/'�j�,/ <br />�,cc�,2�%�o vnJTi� T,, �—c � �c ��is <br />.5i-79i/oni, <br />of— �•`�s�'�=n�lc aJi.cc. N�7'3'F <br />Date <br />Approved as Constructed V � <br />everelt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259�B815 <br />Tjf�= LI�i�/` <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />�p <br />�/ <br />� <br />� <br />♦iA <br />VJ <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less Ihe City ot Everett Irom any and all claims tor damages. cosis, <br />expenses, or causes of ection ihai may arise because of installation <br />and maintenance ol lhe improvement or o�her right�obway use hereto <br />applied for and lurther agrees lo remove same upun notice Irom Ih� <br />Ciry and to replac� public property tlamaged ihereby. <br />Signature of Applicant ' ' Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />7B0 DAYS OF DATE PERMIT IS ISSUEO AND THEREAFTER IS TO <br />BE DILIGENTLV PURSUED TO COMPLETION. THIS P�FMIT AtAY BE <br />CANC[LLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />