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Date <br />�r � �—�� <br />Ppplication For <br />PUBLIC WORKS PERIIAIT <br />Print or 1'ype Only <br />P��ii� Ne,....�,R. � . �� ��s� <br />B�ao. ceo�. . <br />PUEI¢ Nbrhf Fee s <br />To�el Fec - <br />LeuA00� FeePOiC S <br />Balenct�Due S �� �� <br />�,' L��� s� 9' o , o<t f- nR �=�r�rr ' z� y 3s3. �-3so <br />Cwner Mailing Address Ciry : ip Phone <br />Applicant <br />Mailing <br />City 2ip Phone <br />Describe Propase: �'/ork C��n ��""� � Y �!�/�_ �C-�N�T— <br />Prolect Pddress (i� known) ��� � `v�Vv�T_'_5� <br />Attach ;our (4) copies ol plans for proposed work - Draw to scale and note the lollowing as applicable� <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed siructures on ihe lo� <br />• Existing and proposed utilities <br />FI <br />PERMIT CONDITIONS <br />• Centerline ol sireet <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />All calls lor inspection shall be made 2u hrs. in advance - phone 259•881 5. <br />All work shall be performed in accordance with this permit and current City ol [vereit Design and Const: uction <br />Standards and Speci�ications. <br />Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />� Q/� /v _F 6✓iJ � Tv <br />c,Ty oF F� ;f-.���_ <br />� TJ'!a G f1 _FG� <br />as Constructetl <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259�8815 <br />c�F In�S.—d G C E1i PG,�_ <br />� sr� ���,e ,�' � '�`" �c 7 <br />ACKNO\NL[DGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />O <br />� <br />N <br />O <br />a <br />The unAeisigned owner/appGcant hereby agrees to hold and save harm� <br />less the Ciry of Everett Irom any and all claims br damages, costs, <br />� ezpenses, or causes ol action that may arise 6ecause ol installation <br />. i� ,� and maintenance ol the improvemen! �,r nther righPobway use hereto <br />c73c� <br />— applied lor and further agrees to remove same upon nolice irom Ihc <br />Date City aod to replace public property damzyed ihereby. <br />i �` p j� <br />� Li�hl .:l �� LP.i.I. �.2- i � :i'� <br />Signature ol Apn���ant Date <br />WORK AUTHORI2ED BY THIS PF.RMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF �ATE PERMIT IS ISSUED AND THEREAFTEFi IS TO <br />BE DILIGENTLV PURSUED TO COM1IPLETION. THIS PERMIT MAY BC <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />� <br />: <br />tr'�7 <br />H "~.' <br />H � <br />N C <br />� � <br />c <br />�1 �. <br />� <br />�: <br />�� <br />�� <br />�� <br />� <br />J � <br />�: <br />C ; <br />� <br />ti <br />