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Date�� F / <br />Application For <br />PUBI_IC WORKS PER,MI� <br />Print or Type Oniy <br />r <br />Mailing <br />Describe Proposed Work <br />Address <br />/f <br />r,,.n:�,:wo�kaao�m�i. �T !�// <br />eieq oept.. — <br />Pub�R Wo�ka Fee 5 <br />.a,a� Fea <br />tes, PCo�. Fae Pe�a � <br />g ���d <br />Balance �ua <br />Zip phone <br />13�15 PJk••�� ?�,1- 7�3 I <br />LI�J i .." <br />Project Address (if known) _ <br />qitach lour (41 copies of plans for proposed work - Draw to scale and note Ihe lollowing ai applii able: <br />• Property Lines <br />!(lutline and dimensions ol all eristing and <br />propo5ed SlrucWreS on the lat <br />• Existing and proposed utilities <br />• Genterline o slree <br />• Indicale Norih <br />• Show any pwposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />;. Ail calis for inspedion shall be mede 24 h�s. in advance � n��one 259•8815. <br />2 All work shall be pe�iormed in accordance with this permit and current City of Evereu Design and Construction <br />Sta idards and Specilicatlons. <br />3. Call Location Underground Servico 48 hrs. before you di�. TOLL FREE NUMAER 1•S00•424•5555. <br />f <br />s�ND � <br />`,� y � �,�(` <br />c.,; k^� � � ''� �'F <br />Tf/i.5 A.2r� <br />s�ro <br />CJ . ✓�E'J <br />`�.� f�'' o�^ - /? -b'� <br />Ap roved for Construction ' Date <br />.�-' ,- !��/ �/' �-�' G � �l' <br />�INA INSPECTION Date <br />�pproved as Conslructed <br />i,�.���.�� PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl. WA 98201 <br />Phone: 259-8915 <br />ACKNOP:I.EDGEMENT OF CONDITIONS <br />W <br />H <br />�w <br />� / <br />� <br />O <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the Ci�y of Everett irom any and all rlaims lor damages, cosls. <br />ezpenses, or causes of aclion Ihal may arise because oi in,lallation <br />and maintenance ol the improvement or othe righFof-way use hereto <br />applied for and further agrees to remove same upon notice irom the <br />Cit .anc�to replace publ�� damafled therebY. <br />� <br />i ; � _i�_yr/ <br />� <br />Si ature of pplicant Date <br />BOR'JA STOF DAT�E PERMIT ISESSUCD AN� HEREAFTEF ISHTO <br />BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT IJ�l+V 3E <br />CANCELLED BY THE CITY UPON 1,N1' STOPP%�GE OP 1'JORK ON THiS <br />PROJECT OVER 90 DAYS DURATIUN <br />4 <br />f <br />