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Date- L ' _e3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />5Qot-lomlbtJ <br />Applicant <br />Mailing <br />ci>. To. <br />Address <br />Describe Proposed Work MC; Lci Mt QX <br />Project Address (if known) 4� <br />7 L <br />Publ¢ Works Parma • <br />Blna Dept <br />Public Works Fee <br />Tnlal Fee S <br />Less AppL Fee Paid S <br />Balance Due IAS <br />VUZ zi 9a-uxo z58--4►6,e5 <br />City Zip Phone <br />r.IL-EE" 'Z�Q-lSLrx-L /&LL. M,C4Lr_ <br />Gny <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on 'he lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />Phone <br />i 0A <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8815, <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800.424.5555. <br />e-Lo5UTze W- ,q-Pl%A-mee: l-"4 %/- W L- <br />/C� l f �l L �p/1 F21� �I (v/{ C L /L1�i179D 1✓[ <br />91vTGD, <br />P'45 To <br />C rfL� Ain JDNO-a'�l-MATR'4`1. <br />CAL, tzc <br />Approved for Construction Date <br />/-- <br />FINAL INSPECTION Date <br />Approved as Constry ted <br />IDPUBLIC WORKS DEPARTMENT <br />EverCedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />CA <br />M <br />O <br />01 <br />z <br />O <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />�tl aw --en(rStUu 1a-5-t73 <br />Signature of Applicant Date <br />WORK AUTHORIZED B` THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />