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Date�� � � r„ni��.v:mwsr�imn• <br /> Applitali0n For u�no o.n� • ���� <br /> PUBLIC WORKS PERMIT Put�i�cWo.w�fee <br /> iotol Fee a <br /> �ess ann��ee ae�a S <br /> Bainnce0un s <br /> Print or Type Only <br /> I�;s�un� 1��}���n.�.�+a+ JKG 3�ab Ku�I�Ar�.o. .E✓e�etf ��Pza/ d59—3 7S/ <br /> Owner Mailing Address C1ty Zip phone <br /> � Applicgnt Mai�ing Atldress Cdy Ln PI•onu <br /> Describe Proposed Work ��(�]r"0.�Q- ��[I.S�i A d � ��'1� D DO!�_ <br /> Prolect Atltlress lif known� �i�oZ�p R�I� � <br /> � <br /> Atiach lour�4)coples of plans lor proposed work-Drew to scale and note the lollowing as apPlicable�. � <br /> � • P�operty Lines • Centerline of sireet � <br /> � • Outline and dimencions ol all existmg and • Intlicate North <br /> � proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> � DO NOT WRITE BELOW TNIS LINE <br /> PERMIT CONDITIONS O <br /> 1.All cal�s lor inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work sheli be peAormed in accordance with this permit and current City ol Everett Design and Construction <br /> Stentlerds and Specifications. <br /> � 3.Call Locahon Underground Service 4B hrs.belore you dig.TOLL FREE NUMBER 1•800-424-5555. � . <br /> �UBGlC LVO��s' �OT �P�QUi�P�� O <br /> 3��� /�� <br /> �� Y♦ <br /> O <br /> a <br /> �CKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm• <br /> less the Ciry ol Everett from any and all claims lor damages, costs, <br /> expenses. or causes of acfion that may arise because o� ir .tallation <br /> and maintenance ot the improvemenl or other right-ol-way use hereto <br /> applieA for and luriher agrees to romove same upon notice irom the <br /> Approved lor Construdion Date Ciry and to replace public property damaged there6y. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signalure ol ApPficant Date <br /> everetl PUBIICWOqKSDEPARTMENT WORK AUTIIORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> O 3200CedarSireel 180 DAYS OF DAT(: PERMIT IS ISSUED AND 7HEREAFTER IS TO <br /> EveretL WA 98201 BE DILIGENTLY PURSU[D TO COMPLETION. THIS PEPMIT MAY BE <br /> Phone:259�8810 CANC[LLED BV THE CITY UPON ANY S:OPP�GE OF WORK ON THIS <br /> PROJECT OVER 90 OAYS DUF7ATION. <br />