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����� <br /> Dat O � PUOIicWOAaPermlt� ��/� 1 ' <br /> AppNcation Fo� eiaa.oeo�• <br /> PUBLIC WORKS PERMIT Publi�WorkfFee <br /> Tolal Fee s <br /> LessApF�Fea Pai4 S �f,.. <br /> Balancs Due S ��'✓ <br /> Print or Type Only ��pt�flZ7j �G �, �,..�uM.y: <br /> Mar�k �Mon�htn 3r�rn ll��l�nd A�c �cr� ultc N82o3 33�1---3�5Z <br /> � Owner Mailing dress Ciry Zip Phone <br /> Anplicant Mailing Address Ci�y Zip Phone <br /> �e,cribe Proposed Work _l���o� Alck�'and Maqi� �r�Gs �YU11'1_rGZtl^ O�� �o{. <br /> W <br /> Proiect Address(if kiown) �7 Un 14Gtd �l/G __ � <br /> Attach four�4)copies of plans lor proposed work• Draw to scale and note:he tollowing as applicable: � <br /> • Proparty Lines • Centerlino of sireet ♦A <br /> • Outline and dimensions of all existing and • Indicale North V� <br /> proposr.d structures on the tot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE � <br /> PERMIT CONDITIONS <br /> 1.All calla for Inspection shall be mede 24 hrs.in advance•phona 259•881 O. � <br /> 2.All werk she�l be peAormed in accordance with this permit and current City of Everett Design and Construction <br /> Stan,lards end Specifications <br /> 3.Call Locatlon Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> h� I n5tr<<� Gr�x,ia� Gvv�ol Ay di✓ut� la� I?ul�l,a Nla✓Kc I�s(�c�! � <br /> (k�n� C-,�b4.na�^ 33R'7�-��i <br /> � <br /> � <br /> � <br /> Q <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersignetl oK�ner/applicaN hereby agreee to hold and sa��e harm� <br /> less ihe City ol Everett Irom any and all claims for Camages, costs <br /> n e■penses, or causes ol action that may arise Uecause of installatior <br /> ('/�� Y/� L/�..n i1 and maintenance of the improvement or other right•ol�way use herelo <br /> 1�u ��� �--�J�� v applied lor and furiher agrees lo remove same upon notice irom ihe <br /> Approved for Construf.lion ^ City and to replace public property damaged thereby. <br /> C—=C ��--��_/ /-iv- 9� �--�-�- <br /> F�AL INSPECTIOtT � � Date <br /> Approved as Consiructed Signature I Applicant Date <br /> �A�� PUBLICWORKSDEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST 8E STARTI:D WITHI� <br /> 3200CedarStrcet 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAF7ER IS TC <br /> Everell,WA 98201 BE DILIGENT�Y PURSUED TO COMPLFTION. THIS PERMIT MAY BE <br /> CANCELLED BY THE CITY UPON ANV STOPPAGE OF WORK ON THI£ <br /> Phone:259�BB10 PROJECT OVER 90 DAYS DUFATION. <br />