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3 �� Pueecworhsnermn. <br /> Date Z <br /> piag Depl �_ <br /> qpplica�ion Far _ <br /> PUBLIC WORKS PERMIT P�GbcWarkaGee <br /> .o���Fea s_ <br /> �ess noai Fee va�a $ <br /> Oaiance Due S <br /> Print or Type Only <br /> /�a � INCh h/O� �(nl�Y1 � �' �d/iPt� l�J/� �)PTC�� <br /> ��y rnone <br /> �I/Owner Mailing Addres.. ,—� Z�� <br /> S ���Y Phone <br /> App�nt Mailing Addres� Z�� <br /> hi fA� 1 C/ Ilr e pc.Wl 1 <br /> Describe Proposed Work _�..-�-�, <br /> - W <br /> Prolect Address 1il knowN '����-�'--ll"-�1J�-� � <br /> � <br /> Attsch lour(4)copies of plans�or proposed wo�k- Draw to scale and note the following as appGcable: � <br /> • Property Lines • Centerline nl sireel <br /> • Indicate Norih <br /> • Outline and dimensionc oi all eaistiny and � Show any proposed grading changes <br /> proposed strucWres on the lot � Show mezsuremeNs M <br /> • Exis�ing a�d pro?osed utilities W <br /> DO NOT WRITE BF.LOW THIS LI�E O <br /> PERMIT CONDITIONS � <br /> 1.All calls tor inspection shall be made 24 hrs.in advance-phone 259-8810. <br /> 2.All work shall be peAormed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specilications. � <br /> 3.Call Location Underground Service 48 hr;..befure you dig.TOLL FREE NUMBER 1•800-424-5555. <br /> n O <br /> / Gl1LG�-C. Lt�OZI72 �.�fL2>s..c-f .�c/� �vy-C�L'��^' � <br /> 0 <br /> �,�i,/y,� �oo��- � <br /> .3 - � �9� O <br /> a <br /> ACKNOWLEDGEMENI"OF CONDITIONS <br /> The underciyned owneUappliwN hereby aqrees�o hold and save harm- <br /> — less the C�ty ol Everetl iror� any and all claims for damages. costs, <br /> ezpenses, or causes ol action lhat maY arise because ot installation <br /> and maintenance of the improvement cr other rigM-ol�way use herelo <br /> applied br and further agrees to remove same upon notice Irom Ihe <br /> Approved lor Gonstruction Date City and to replace public propertY damaged thereby. <br /> FINAL INSPECTION Date Date <br /> Approved as Consiructed <br /> Signature ol Applicant <br /> WORK AUTHORIZEU RY THIS PERMIT MUST BE STARTED WITHI <br /> evcreu PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PEP�dIT IS ISSU[D AND THEREAFTEF IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSU[D TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,N'A98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8810 PROJECi OVER 90 DAYS DURATION. <br />