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Date _�/A / Pupl¢Y/mk�Permit• `/�y/� Z <br /> Application For eieo-o�oi • �7 /�3/0� <br /> PUBLIC WORKS PERIVIIT PUEI¢WorbFee -�r� <br /> Toi��Fee S /� 'l"J O <br /> Lasf PppL Fee PeiE s <br /> Print or Type Only <br /> 6etnncc0ue s `f� � U G <br /> ,6 P/� 9 <br /> �c�. �c,.b� �2,�, l�li� 12yckere �=�t' S�o2�/ ��-a -aRs� <br /> Owner ldailing Address City Zip Phone <br /> ��12,�n1 l i�M1lnlD�P �o/ a � lUC_ � r�7ap� ��n�4ff'� 9�/.T.3— yx'� -a�=oy <br /> Applicant Malling Address City Zip Phone <br /> Describe Proposed Work �v ,l�ol y � 1o¢��-fJ oy� �Qe�„ <br /> � <br /> � <br /> Pro�ect ACdress(if known) � <br /> Attach�our(4)copies of plans for proposed work- Draw to scale and note ihe lollowing as applicable: � <br /> • P•operty lines • Centerline ol stree� � <br /> • Outline and dimensions ol all existing and • Indiwte Norih <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Exisfi�ig and proposetl uhlities { Show measuremenis � <br /> DO NC�T WRITF BELOW THIS LINE q <br /> PERMIT CONDITIONS � <br /> 1. A�I calls for inspection shall be made 24 hrs. in advance- phone 259•B8�5. � 7 <br /> 2. All work shell be perlormed in accordance with this permit and current City ot Everett D�sign and Construclirc �� <br /> Standards and Specifications. r: <br /> 3. Call Location UnderQround Service 4B hrs. belore you dig.TOLL FREE NUMBER 1-800•424-5555. � � <br /> O <br /> � H F <br /> H �- <br /> N Or <br /> � � <br /> a � ` <br /> � � <br /> r : <br /> � <br /> � <br /> ACKNOWLEDGEMENTOFCONDITIONS � : <br /> J <br /> _ The undersigned ownedapplicant hereby agrees to huld and savr harm� <br /> less the City of Everett Irom any and all claims lor damages, costs, =' <br /> �— / � expenses, or causes of action Ihat may arisc because ol instellation <br /> ` -'"/ �Qf� 3-i s�r `� and maintenance oi the improvement or other righPof�way use hereto ,:: <br /> '-w~ ��-� applied for and further agrees to remove same upon notice irom the "' � <br /> AppsoOed Io�Consiruction � Date City and to replace public property damaged thereby. }:t . <br /> � J�/'�r// t �. ��. . <br /> _�,��f�//✓ \,C�4C"L� ./ � <br /> FlflA� INSPECTION _Z D e C� ���"�� , �'/6-�� � C; <br /> Approved as Constructed Signature of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN e <br /> � 3200 Cedar Sireet 180 DAYS OF DATE PEHMIT IS ISSIIED AND THEREAFTER IS TO <br /> Evereti,WA 98201 8E DILIGENTLV PURSUED TO COMPLFTION. THIS f'ERMIT MAV BE <br /> Phone:259�8815 GANCELLED BY THE CRV UPON ANV 3TOPPAGE OF WORK ON THIS <br /> PROJECT OV[R 90 DAYS DURATIOh. <br />