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TYPE OR PRINT ONLY <br />Owner <br />Appbcatlon For <br />PUBLIC WORKS PERMIT <br />PUE'!_IC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 259-6810 <br />Y-G o) <br />Mailing Address <br />Mailing <br />Describe Proposed Work &c g C JN ru ` A. <br />City <br />Date —7 / <br />Public Works Permit 11 �� O1 / <br />Building Permit a <br />Public Works Fee $ Zo — <br />Cr? <br />City Zip Phone <br />PROJECT ADDRESS (if known) — z 5 3f8 Ave, <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following if applicable: <br />•Property Lines -Outline and dimensions of all existing and proposed structures on the lot 'Existing and proposed utilities <br />'Centerlineof street •Indicate North •Show any proposed gradinq changes 'Show measurements <br />PERMIT CONDITIONS: <br />1. All calls for inspection shall be made 24 hours in advance - phone 259-8810. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and <br />Construction :standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you di . TOLL FREE NUMBER 5-800-424-5555. <br />h fz <br />Ma�hIjv) <br />1�4 <br />,,0 <br />Approved as Constructed <br />0c-1r-98 1:�Y'r't1 <br />it 98017 <br />OTHER 20.00 <br />c nTA� 20.00 <br />- '2 <br />W <br />V♦ <br />co <br />0 <br />n <br />z <br />0 <br />V♦ <br />0 <br />a <br />CASH 2O.00 <br />,} nH4454 <br />4ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees in hold and save harmless <br />the City of Everett from any and all claims for damages, costs, expenses, or <br />causes of action that may arise because of installation and maintenance of <br />the improvement or other right-of-way use hereto applied for ano further agrees <br />to remove same upon notice from the City and to replace puolic property <br />damaged thereby. <br />1„ �-ir sc21 l7�Y5f <br />Signature rf pp ant Date <br />WORK COMPLETION.TIH S PERMIT MAY BE CANCELLED BY THDE CITY (N 180 DAYS OF DATE UPON ANY STOPPAGE OFfIT IS ISSUED AND THEREAFTER IS TO BE '^'I ORK ON THIS PROJECT OVER 90 DAYS DURATION. DILIGENTLY PURSUED TO <br />RATION. <br />