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�Y�VY-� Pul��if.WOrY\Pn�m�l=� _ � / ,�V <br /> Date "' ��� '�� <br /> Ginq Oeo� � - V I �Y^-�� <br /> ApPlicatienPor _______. ____ <br /> PUBLIC WORKS PERMIT P°°''°W°"""` <br /> ,o�.���� 5— <br /> less<no� VePra�o S -- <br /> oaian�r(l�r S <br /> Print or Type Only <br /> � � �,� �., ��., � , a�� �►��?- �� L, �r�- acao 1 <br /> /� }��' �// � ��la' I lY !f � Phone <br /> F',"�"�y�f+ Madmg Address C�ty 7 n <br /> Owner �J <br /> �� —IIJ�-� � <br /> Applicant <br /> Mailing Add�ess City Lp Phone <br /> Descnbc Proposed Work <br /> ��4'li�l�-- 'Pi�Yr'�Y��--' -- <br /> - W <br /> P�ojeCl AdGre55lil knownl `-r�� � � � <br /> � <br /> Attach four(4)cop�es ol plans lor proposed work� D�aw to scale antl note Ihe lollowing as apUlicable: � <br /> • Property Lines • Centerline ol slreet <br /> • O�tline and dimensions oi all ex�sting and • Indicate Norih <br /> proposetl siructures on Ihe lot • Show any proposed grading ohanges <br /> • ExisUng and proposed utilities • Show measurements M <br /> W <br /> DO NOT WPIiF BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> t.All calls tor inspection shall be made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be pedormed in accordance with ihis permit and current City ot Everelt Design and Consiruction <br /> Standards and Specitications. � <br /> 3.Call Location Underground Service 49 hrs.be�ore you dig.TOLL FREE NUMBER 1-800•424•5555. <br /> r J O <br /> �,� ���L��- /�,b� �'c�c�rr�k.� �� � <br /> `� � <br /> ,�Z,��� �� N <br /> � ��-d9 0 <br /> a <br /> ACKNOWLEDG[MENT OF GONDI�IONS <br /> The undersigned owner/apPlicaM hereby agrees to hold and save harm- <br /> — less ihe City ol Everett Irom any and all claims lor damages, costs. <br /> eapenses, or causes of action that may arise because ol installation <br /> and mamlr.na�ce of thr improvement or olher right�ol-way use hereto <br /> applied lor and 'urlher agrces to remove same upon notice Irom Ihe <br /> ApproveL�or Construclion Date City and to replace public properiy damagetl thereby. <br /> FINAL INSPECTION �a�� Date <br /> Approved as Constructed Signature ol Apl�hcant <br /> WORK AUiHORIZEO BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEF:.RTMENT 180 D�YS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarSireet BE DILIGENTLY PURSUED TO COMPLETION. THIS PEHMIT MAV BE <br /> Everelt.WA9(3201 CANCELLEO BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�6810 PROJC-CT OVER 90 DAYS DURATION. <br />