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Date / �U S9 ���,�, ,......�.,..� -- ---- <br /> o�np o•o� • - <br /> Applicatlon Po� <br /> PUBLiC WORKS PERMIT "°°'ro.�:`Pe ; — <br /> .ess�oo����P��� 5 <br /> Baiance0ue 5 <br /> Print or Type Only <br /> Madina ACdress Clty Lp Phone / <br /> owner G�:az�L aCIG — .�i ?�> � <br /> �VNDA J� �os� 3� 35 T�� A �=� EvERcr 9���1 as9- � 3�8 <br /> 4PPhGanl <br /> Mailm9 Address C�ty Lp Phone <br /> Describe Proposed Work � <br /> W <br /> Projec�Addre55lil known) <br /> 3 �"=� S�" �e�urct,,,, �'01 �acw-� -f 3�3 5�� � <br /> � <br /> Attach�our 141 copies ol plans lor proposed work• Draw to scale and note�he lollowing as applicaUle: � <br /> • Property Lines • Centedine ol slreet <br /> • Oulline and Aimensions ol all ezisting ard • Indicate North <br /> proposed s�ructures on IhP lot • Show any proposed grading cnanges <br /> • Existing and proposed utilltie� i Show measurements M <br /> W <br /> UO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> 1,Ail calls for inspection shall be made 24 hrs.in advance•phone 259•88�0. <br /> 2,All work shall be oertormed in accordance with this permit and current City ot Everett Design and Construction <br /> Standards and Specifications. � <br /> 3.Call Location Underground Service 4B hrs.helore you dig.TOLL FREE NUMBER 1-800•424•5555. <br /> O <br /> �w <br /> _/ <br /> O <br /> a <br /> 1ChNOVJLEDGEMENT OF CONDITIONS <br /> The undersigned owner/appl�.cant hereby agrees lo hold and save harm• <br /> less the City ol Evemtt Irom any and all claims br dama9es, cosls, <br /> expenses, or causes of aclion �hat may arise because of installation <br /> and maintenance ol Ihe Improvement or olher nght-obway use hereto <br /> applieJ lor and luriher agrees to remove same upon nolice irom Ihe <br /> Approved lor onstruc���^n �a�e Ciry and lo replace public propeny damagad�hereby. <br /> Date '�"'�' � � /�� <br /> FINAI INSPEGTION Si ature ol App� ant Dale <br /> Appwvea as ConsUucted <br /> ORK AUTH IZED B HIS PERMIT MUST BE STARTED WI <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cetlar Strcat BE DILIGENTLY PURSIJED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLF.D �Y THE CI7Y UPON ANY STOPPAGE OF 1NORK ON THIS <br /> Phone:259�BB70 PROJECT OV[R 90 DAVS CUHATION. <br />