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Date �� 3 E <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />v�' ,���¢r r� 3?A� �FAAR ���N <br />Mailing <br />' �� - �yti <br />��oecPla�ksPermil. - <br />BiOg OeO�� � — <br />ruobc wvwe ice s <br />Totel �ce <br />Less Aool. iee PeiE $ '/ <br />Balancc Due S ^�� �A��� <br />9�x'I zs'9 a�z� <br />up <br />S�rz <br />Applicant Mailin9 Atldress City Zip Phone <br />Describe Proposed Work <br />�<.� �,y�,��� 9syd' e� F,K ���T ,a <br />�x�5�'1_— �'� S%�c.'�C� rl i E✓LLi7'� WMFiTWihT,� T�F.1�'wi<^.VT" i4:M�� CuAnF� <br />u�-w.D <br />Prolect Address (if known) <br />Attach lour �4) copies ol plans lor proposea work • Draw to ecale and note ihe following as applicable: <br />• Property Lines • Cente�line of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed struclures on the lot • Show any proposetl grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />All calls for inspection snall be made 24 hrs. in advance - phone 259•881 5. <br />All work shall be periormed in accordance with ihis permit and current City ol Everett Design and Construction <br />Stantlards and Speciliwtions. <br />Call Location Undr.rgiound Service 48 hrs. betore yeu dig. TOLL FREE NUMBER 1•800•424-5555. <br />�/ <br />� <br />Approved as Constru�ted <br />evrrett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />EveretL 1YA 98207 <br />Phane:759�8815 <br />ACKNOWLEDG[MENT OF CONDITIONS <br />� <br />O <br />� <br />N <br />O <br />a <br />The undersigned owneUappliwnt hereby agrees to hold and save harm� <br />Iess the Ciry of Everett irom any and all claims lor damages, costs. <br />/ expenses, or causes of 2ction Ihat may arise Uecause ot installation <br />�� and maintenance of Ihe improvement or olher riyht�of-way use hereto <br />1..-- applieC for and lurther agrees to remove same upon notice Irom ihe <br />Date City and �o replace pubGc property damaged ihereby. <br />�o�-�'-7� lI/3/86 <br />Datc <br />Signature ol App icant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST EE STAHTED WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEN IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />