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Date <br />Applicelion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />EV C-I�t� FC��isl- <br />Mailing <br />City <br />Zip <br />v�ee� won. n.,m�u 8%� "•�09 <br />BiCp. �eot • � g �S <br />PUGI�cWOMSFee S <br />Tot�l Fsa <br />Leu �DD� Fae P�iE � <br />B�I�nuDus s�79•?'/ <br />/'�i� ii-.�in'._ ot/ <br />Phone <br />�eecrlba Proposed WoUrk �C� ���+ R�� 1`�' r�'�� �� �� �15� N� <br />jwO W,N L F — <br />Prolect Address Ot known) <br />Attech four (4) copies ol plans for proposed work • Draw lo scale and note the tollowing as applicable: <br />• Property Linae • Centerline of street <br />• Outline end dimensions ol ell existinB end • Indicate North <br />proposed struclures on the lot • Show any proposed greding changes <br />• Existing and proposad utilitias ��j� ��Z� � Show measuremenis <br />PERMIT CONDITIONS <br />1. All calls tor inspection shall be made 24 hrs. in advance � phone 259•8815. <br />2. A�I work shell be peAormed in accordance with ihis pernit and curreN Ciry of Evzred Design and Consirudion <br />SlanAerds end Specilicationa <br />3. Cell Location Underpround Sarvice 48 hrs. before you dig. TOLL FREE NUMBFR 1•800•424-5555. <br />y, TO d6 Cv,vsr•eo<T�Fv AS �E.�' �'La �/ A-� <br />A POi2Gl�E� .4.f/!> ,D<i TE".c? /O — B — �� . <br />�i�,,� �az.l.� /O-�P-� <br />ApproveA for onstruction Date <br />�� dl� /�'�1 L -��/ <br />F�NAL INSPECTION Date <br />Approved es Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Stree� <br />Everett, WA 98201 <br />Phone:259�8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersignetl oH �ar/applicant hereby a0rees to hold and save harm- <br />less ihe City ol Everett trom any and all claims lor damages, costs, <br />eapenses, or causes ol action that may arise because of installation <br />and mainlenance ol Ihe improvement or other right•ol�way use hereto <br />applied �or and luriher agrees lo remove same upon notice Irom the <br />C�ty and to replaca li�property d meged iher 6y. <br />U�-cG..�-� �Do�t � 9�2�4-�f- <br />• -- l � _.�>4 �� -z3-B9 <br />Signature ol Applicanl Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND TH�REAFTER IS TO <br />B[ UILIGENTLY PURSUED TO COMPLETION. THIS FERMIT MAY BE <br />CANCELIED BY THE GiY UPON ANY STOPPAGE OF V,�ORK ON THIS <br />PROJECT OVER 50 DAYS DURATION. <br />H H <br />H 'Tl <br />N .T. <br />�m <br />�� <br />� <br />� M <br />2 <br />S <br />�M <br />N <br />� � <br />�N <br />�� <br />. � <br />� <br />� <br />N <br />� <br />� <br />