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Date ����� <br />� AppliCa�ion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />��.,�' <br />� — <br />I`74��i�i�., 1'>c..c� L n <br />Owner Mailing AtlAr� <br />-� o � - > �--c <br />�J. �a l�� . .i � 7...� > <br />Applicant Mailing Addn <br />Describe Proposed Wark <br />G ..c..Q. � <br />��sa /1.....,Q 1-o Ri, .•.� <br />� <br />L U J<- (t C✓ L <br />PuOiic Worwe Permit • v �� <br />Biap Depl • <br />Ppbllc Woiks Fee S '�p (% <br />Tolel Fee <br />LCss ROD�� Fca P9�4 S <br />Badn«Ou0 s <br />�7 ��_ <br />i��: o. 5�'-r 1_ .,�_,� 11 <br />City Zip <br />,f� /}..' s I:���F{ W�sC. <br />n <br />�i- K-c -..�.� -- <br />�to.•�. <br />7 <br />1�✓�s <br />�,.c -z>>/ <br />S-z �� <br />Phone <br />5c:��� <br />Phone <br />7• <br />�. .i ��... <br />i <br />_. ..." f �' J� c s <br />. <br />Project Addrees (il known) <br />Attach lour (4) copies of plans lor proposed work • Draw lo scale and note ihe Iellowing as applicable: <br />i Property Lines • Centerline of sireet <br />• Oulline and dimensions ot all exisling and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Ezisting and proposed utili�ies • Show measurements <br />FERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All work shall be performed in accordance wilh ihis permit and current City ol Everett Design and Consiruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424-5555. <br />y /�'i,Q,:� r�9�a �r�v�,� �i�c cv� T,e'oG <br />�� ,4�v�.r�� ��.a-1c oi= �.�.Pr = �o���r <br />� n t /�� % //' E� <br />App ed lor Construct� Date <br />�—>��-�[ Y� �a�lo -�j <br />F�L INSPECTION Date <br />Approved as Construc�ed <br />evere�t PUBLIC WORY,S DEPARTMENT <br />� 3200 Cedar Street <br />Everett WA 98201 <br />Phone:259�8815 <br />W <br />M <br />� <br />� <br />0 <br />� <br />� <br />0 <br />11/�1/86 11:08RN OOQAN3054� <br />/ <br />N0008338:. <br />DFT.20 420.00 <br />ACKNOWLED(�C�FF�JT OF �Q�IONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less Ihe Ciry of Everett trom any and all claims for damages. costs, <br />eapenses, or causes ot action Ihat may arise because ol installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and lurther agrees to remove same upon notice Irom ihe <br />City and to replace public property damaged thereby. <br />� �/ � / �N.r+/ <br />� � cJ J � i�n.% 1 �' ( � F6 <br />i ���-+�\ -C-�_�� � <br />Signature ol Applicant Da�e <br />WORK AUTHORIZED BV THIS PEHMIT MUST BE STAFTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREC,F7ER IS TO <br />BE DILIGENTIY PURSUED TO COMPLETION. THIS PER�1(! MAY BE <br />CANCELLED BV THE CITY UPON ANY STOPPAGE OF �VORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />