Laserfiche WebLink
Date.�'�7 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Clr O� rJD ,2.f3.:t V�l�lr <br />Meiling �ddress <br />• ,zs"3..2 ✓�'REinI;FI F <br />Mailing Address <br />�I <br />�,,�,��� vr�,,,. ���,m,, . _�7-99 <br />uiap �eM • <br />romm woM1.n res <br />romiFnc S _ <br />t�.ss nnv� �=^o v.,�e 5 0 00 <br />n,d���:� n,�- S ca� <br />�JA';�u! �? ��.J-/� <br />Zip Phone <br />Phone <br />-io32 <br />DescribeProposedWork iNSTi��c i�>An/J�CAf���� i9CC�=sS �'�7i�� adEK �=.r�'sTiiJG <br />Prolect Address (il known) <br />� <br />Attach lour (4) copies ol plans lor proposed woik • Draw to scale and nute Ihe lollowing as applicable: <br />• Properry lines <br />• Outline and dimensions of all existing and <br />proposed s!ruclures on ihe bl <br />• Ezisting and proposed utilities <br />• Centerline of street <br />• Indica;e horth <br />• Show any proposed grading change:. <br />• Show measuremen�s <br />PERMIT CONDITIONS <br />1. All calls lor insuection shall be made 24 hrs. in advence - phone 259-88� 5. <br />2. All work shall be performed in accordance with this p=rmit and current City ol Everett Desiyn and Construclion <br />Standards and Specificalions. <br />3. Call loca�ion Underground Service 48 hrs. before you diy TOLL FREE NUMBER 1•800•�:24-55$5. <br />— —� <br />��-���� �/,.�/8 � <br />Approved (or C nsiruction Date <br />� d- -./ � 7 <br />FINAL INSPECTION Date <br />Appruved as Constructed <br />��i��❑ PUBLIC WCRKS DEPARTMENT <br />� J200 Gedar Street <br />Everefl. WA 98207 <br />Pnane:259�8815 <br />ACKNOWLEDGEMGNT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />7he urAers:gned owneqapplicant hereby agrees to hold and save harm- <br />less the CAy of Everelt hum any and all claims for damages, cosls, <br />expenses, or causes ol action that may arise because o` insiallation <br />and maintenance of the improvemenl or other righl�of�wa�i use hereto <br />applied tor and further agrees lo remove same upon notice Irom the <br />City and to replace public properly damaged lhereby. <br />�ii� <br />"„L �c>..i7'!'� /,''Zii.utc�, S,':� /�'7 <br />Signatwe of Applicant Dete <br />WORK �UTHOAIZED BY THIS PERMIT MUST BE ST�RTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUEO TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON Ti11S <br />PROJ[CT OVER 90 DAYS DURATION. <br />