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Date�.1 S �'�����c Worb PPrmn• <br /> B�ea DeDI.. � ' . <br /> Application For <br /> PUBLIC WORKS PERMIT PunTc�N�ioPnFee S — <br /> Lass Rool Lea Ps0 S�� <br /> Oalenc!Dvu � �'—��� <br /> Print or Type Only <br /> �L�Pa i V J�l,ou,�r ,ti � G� ; ���. � ,�� f1t.�. ,�=„�,�tf- 9�z�� a�,�-���r� <br /> Owner Mailing Address City Zip Phone <br /> SQ ,�,i — <br /> Applicanl Maihng Address City Zip Phone <br /> Describe Proposed Work � <br /> �J W <br /> Prolect Address Of known) l"L�_..�'��d-/71�' — � I <br /> Attach four(4)copies of plans lor proposed work- Draw to scale antl note the lollowing as applicable: � <br /> • Property Lmes • Centerline ol street � I <br /> • Outline and dimensions o1 all ezisting and • Indicate No�th <br /> proF�sed structures on the lot • Show any proposed grading changes � <br /> � Eaisting anC proposed utilities • Show measurements M � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls Icr inspection shall be made 24 hrs.in advance•phone 259•8610. � . <br /> 2.All work shall be peAormed in accordance with this permit and current City ol Everett Design and Construction <br /> Standerds and Specifications. <br /> 3.Call Location Underground Service ee hre,belore you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> i <br /> l��- � � 9'�� .�� �, �`�,� �' z°� Q � <br /> � <br /> � °'�� � <br /> � <br /> � <br /> a <br /> ACKNOWLEDG[MENT OF CONDITIONS <br /> The untlersigned owner/appllcant hcreby agrees to hold and save harm• <br /> - less Ihe Gty of Everelt Irom any and all claims for tlamages. costs, <br /> ��� expenses, or causes ol action Ihat may a�ise because of installation <br /> L // � OB and maintenance ol Ihe improvement or other ngh4ol-way use hereto <br /> � apv��ed lor and Wrther agrees to remove same upon notice Irom the <br /> Approved lor Construction �a�e Ciry and to replace pubGe property damaged thereby. <br /> ��� �a�-6S <br /> INSPECTION Dale Date <br /> Approved as Gonsiructed Signature of Applicant <br /> WORK AU'HORIZHD �Y THIS 1'ERMIT MUST BE STARTE� WITHIN <br /> everetl PUBLIC WORKS DEPARTMENT 180 DAYS OF OATE PERIdIT IS ISSUED AND THEREAFTER IS TO <br /> � 32G0 Cedar Sheet �[ DIUGENTLV PURSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Everetl.WA 98201 CANCELLflD BY THE GTY UPON ANY S70PPAGE OF WORK ON TNIS <br /> phone.259-A0�0 PROJLGT OVER 90 DAVS D JRAiION. <br />