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Date 3 6 Q� -- �„�,�,�.w���,��,.,m,�. <br /> APPIiCa�lon Fm [ana o�m • _�� /�y� <br /> PUBLIC WORKS PERMIT ���'�;o„���`�° : �--- <br /> I Less nnoi �oe rn�n S_ <br /> Print or Type Only ea�a��eo�� s <br /> Lah�l�-+- �so� 3Q� �,�r�p�Av.� "-3Dy`c �✓n,a � Sd'ao� �zs �z�� <br /> Owner Mailing Address City Zip Phone <br /> .SarN e <br /> Applicant Mailing AdAress City Zin Phone <br /> Describe Proposetl Work � P Y1D/l��Q��✓�/M P/I'l � ���i—S, _ <br /> Project Addree,I�1 known) �np�_��llC.1CA! �Ue 5���3�.Tj � <br /> AUach four(4�copies ot plans lor propused work• Dra v to scale and note the lollo�ving as applicable: �, <br /> • Property Lines • Centerline ol streel � <br /> • Outline and dimensions ol all existing and • Intlicate Nor�h <br /> proposetl siructures on the lot • Show any proposed grading changes <br /> • ExisUng and proposetl utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LI�E O <br /> PERMIT CONDITIONS <br /> 1.All calls tor lnspection shall be made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shell be pertorrtied in accordance with this permit and current City of Everett Design and Consiruction <br /> Standards and Specifitations. <br /> 3.Call Location Underground Service 48 hrs.belora you di9.TOLL FREE NUMBER 1•800-424•5555. � <br /> ��L- �� -4�1:.:12-V�1 l 1 ��U( �-� O <br /> � ,I /Z /`' � � <br /> 1 � V� <br /> ��l�c� a <br /> ACI<f�OWLFOG[AIENT O�CONDITIONS <br /> The undersigned owneriapplir.aN heret�c agrees lo hold and save harm� <br /> — less Ihe City of Everett Irom any ;,n ' " claims lor damages. costs, <br /> expenses, or causes ol action that m�, �ise because ot installation <br /> and mamtenance ol the improven.en ^r o� ier righl-of�way use hereto <br /> applied for and lurther agrees ;o re .o:� �ame upon notice trom the <br /> Approved lor Construction Date City and Io reUlace public properN C, �-ie�ed themby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed SignaWre ol Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THI� PERMIT MUST BE STARTED WITHIN <br /> � 3200CetlarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THERE/.rTER IS TO <br /> Everett,WA 98201 BE DILIGENTLY f'IiRSUE[1 TO COMPLETION. THIS PERMIT MAV B[ <br /> Phone:259�8810 CANCELLED BY TIiE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVHR 90 DAVS DUR�TION. <br />