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Date�`D O ��o �wo,���������.j �7� <br /> Application For eiep oeP� •_C2��/(�5,�__ <br /> PUBLIC WORKS PERMIT Pu`TolrFeoFeB = <br /> Less ApO�Fee Pai� 5 <br /> Baiancc�ue $_ <br /> Print or Type Only <br /> ��-a�'t ��i�� 3�-1�1 �i���L�n �u�rr-� ►J;� Qg�v I�-�►��� <br /> Owner Mailing Address T City Zip Phone <br /> � <br /> Applicant Mailing Address City Zip Phone <br /> Descrihe Proposed Work �� �� <br /> - W <br /> Proiecl Add�ess(if known) � <br /> Attach four(4) copies ol plans for proposed work� Draw to scale and nole Ihe following as applicable: � <br /> • Property Lines • Cr.nterlinc ol sireet ♦A <br /> • Outline and dimensions of all existing and • Indicate North V� <br /> preposed structures on Ihe lot • Show any proposed grading changes <br /> • Ezisting and proposed utilitias • Show mcasurements � <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERM17"CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259-8810. � <br /> 2.All work shall be pedormed in accordance with this permit and current Cily of Everett Design and Construction <br /> Standards and Spedtications. <br /> 3.Call Lncation Underground Service 48 hrs.belore you dig.TOLL FREE hUMBER 1•800•424•5555. � <br /> / Glv�'L/C GCIQ�.�S� �'h1// �llT' ��f�U/.c'�p O <br /> 3 Z2 J�g � <br /> / <br /> N <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> 7he undersignetl ownedapplicant hereby agrees tn hold antl save harm� <br /> less ihe City oi Fverett from any and all claims lor dama�es, costs. <br /> ezpenses, or causes of action Ihat may anse because ol installation <br /> and maintenance of the improvement or other nght-obway use hereto <br /> applied lor and Iwlher agrees to remove same upon notir.e Irnm the <br /> Appmved lOr ConSiruc(ion Date City and to replace public property damaged tnereby. <br /> FINAL INSPECTION Date _.. <br /> Approved as Con5lrucied Sic�na�ure of Applicant Dale <br /> everelt PUBLIC WORKS DEPARTMENT �NORK AUTHORIZED BY THIS PERMIT MUST BE ST�RTED WI7HIN <br /> � 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED ANO THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone.259-8810 GANCELLED BY THE CITY UPON ANY STOPPACE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />