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Date�� <br />� � � Application For <br />� PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />Mailing <br />/� <br />Describe Proposed Work <br />/ L G hGC� <br />PuEIm Waka Permi� � _ O� � / <br />nma. 6 c o'. � _ <br />vublw Worke Fee s <br />Tot�l Fea <br />less Appl Fee PeiC S <br />Betance Due s � <br />(,d� 25Z-7$// <br />cip ruvuc <br />Prolect Address (if known) <br />Atlech four �4) copies of plans for proposed work • Draw to scale and note ihe following as appllcable: <br />• Property Lines • Centerline ol sireel <br />• Outline and dimensions ol all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show mezsuremenls <br />PERMIT CONDITIONS <br />1. All calla tor inspection shell be rt:�. � hrs. in advance - phone 259•8810• <br />2. All work ahell be pedormed In aa oi dence with this permit and current City of Everett Design and Conatruction <br />Standerds end Specifications. <br />3. Call Location Underqround Service 4B hrs. before you dig. TDLL FREE NUMBER 1•800-424-5555. <br />INITIAL �NSPECTION <br />_ KIHK 9Fi00KS <br />DATE _ 3 7 9 � <br />Approved � n � � ate � <br />AL9NSPECTI(iN <br />Approved as Conslr ��. `� �D <br />�PUBLIC WORKS DEPARTMENT � <br />3200 Cedar Street <br />Everett, WA 9B201 <br />Phone:259�BB10 <br />��� ��CD <br />1 01994 <br />MAR <br />... . ........... <br />(;ITY OF EVERtTI <br />puiidinp Division <br />� <br />O <br />ACKNOWLEDGEMENT OF CONDiTIONS <br />The undersigned owner/applicant hereby agrees' � hold and save harm- <br />less the Ciry ot Everetl Oom any and all claims for damages, costs, <br />expenses, or causes of action ihat may arise because of installation <br />and ma�ntenance ol ihe improvement or other righ�-obway u&e hPretu <br />applied lor and further agrees lo remove same upon notice from the <br />City and to replace�ic property damaged ihereby. <br />Oate <br />Signature ot Applicant <br />BORDAYSTOF DATE PERMIT ISEISS ED AND THER AFTER ISHTO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANGELLED BV THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUF7ATION. <br />