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i <br /> Date �-I �-S�� r�ne�wo�xs n���� <br /> 4pplication For einp ocni • <br /> PUBLIC WORKS PERMIT °°°�°W°,�,�°d — <br /> Tnlel Fr9 s <br /> Less Aop�-Foc Paid S <br /> Belancnpuc S <br /> Print or Type Only <br /> I ����r�-� ��-c�- i��r � �� �1,� �� ��r� �i�l � <br /> � Owner Mai'��gAddress C�ty ZiP Phone <br /> ����i <br /> Applicant Mailing Adtlres� Cdy ZiP Phone <br /> Describe Proposed Work �/`� �� t�.l!�-!— <br /> - W <br /> Prolect Address Id known) — � <br /> Attach four 14)copies of plans for pmposed work- Dr lo scale and nete�he following as applicable: � <br /> • Property Lines • Centerline ol street � <br /> • Oulline and dimensions of all e<i;ting and • Indiwte Nonh <br /> proposeC siructures on th=b� • Show any proposed grading changes <br /> • Ezisting and proposed utilities • Show measuremeMs � <br /> DO NOT WRITE BELOW THIS LINE O <br /> �ERMIT CONDITIONS <br /> 1.All calls for Inspection shall be mede 24 hrs.in adeance•phone 259•8810. � <br /> 2.All work shall be peMormed in accordance with thi^,permit end current Cily ol Everelt Design and Construction <br /> Standards end Specitications. <br /> 3.Call Localion Underground Service 4B hrs.before you dig.TOLL FREE NUMBER 1•800�424•5555. � <br /> 11or g�c�r.�i2� _ O <br /> , � <br /> /��� N <br /> 0 <br /> a <br /> ACKNOWLEDGEP.4ENT OF:.ONDITIONS <br /> The undersigned ownedapplicanl hereby��yrees�.o heh:and save harm� �1;} <br /> less the City ol Everelt Irom any and all claims for damages. costs. <br /> expenses. or causes of action ihat may arise because ol installntion <br /> and mainlenance of the improvement or other ri9hl�ohway use hereto <br /> applied lor and luriher ac�rees to remove same upon notice irom iFe <br /> Approved for Conslruc�ion �a1e Cdy and to replace public property damaged Ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Construded Signature of App!icant De�e <br /> WORK AUTHOHI2ED BY THIS PERMIT �IUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 1B0 DAVS OF DATE PERMIT IS ISSUEU AND THEREAFTER IS TO <br /> � 3200CederStreet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everelt.WAP8201 CANCElLEO BY THE CI7Y UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�0810 PROJECT OVER 90 DAYS DURATION. <br />