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Dale "� �� <br />Aoplication �or <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Apphcant <br />Describe Proposed Work <br />Project Address lif known� <br />Mailinc� Atldress <br />Cuy <br />2ic <br />Atlach tow (4) copies ol plans for proPosed work � Draw to scale antl note Ihe following as appficahle: <br />• Property Lines <br />• Outline and dimensions of all existing antl <br />proposetl strucWres on the lot <br />• Existing and proposed utilities <br />Pubhc WarAs Pvi I • ' � <br />���/./}� <br />�in9 D,.pi . _ ��--/-'.� _ ._ . <br />F,�mmworv.Ice ZOIQ7'' --.. <br />rotq� Fee $ — - <br />�essAnnl Fae Pnid S <br />�,�.,nc� Du� S Z D <br />• Genteihne ol streel <br />• Indicale Norih <br />• Show any proposed gr�tlmg changes <br />• Show measuremenls <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be m� �ie 24 hrs. in advance - phone 259•8810. <br />2. All wOrk shall be pedormed in accordance with this permit and current Ciry of Everetl Design and Consiruction <br />Standards and Specificalions. <br />3. Call Location Underground Service <8 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />-"//� / / / <br />, V�!'.�j)%(/�^! /�)!l9/S ,czl�!! J "� �"�'� <br />/� <br />Approved as Constructec <br />everett PUBLIC WORKS DEPAR7MENT <br />� 3200 Cedar Street <br />Everett, WA 9A201 <br />Phone:259�8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owneVapPlicant here�y a9rees to hold and save harm� <br />Iess the City ol Everett from any and all claims lor damages, cosSs. <br />ezpenses. or causes of action ihat may arise because ot installation <br />and mainlenance ol the iinprovement or other nght�of-way use herelo <br />applied for and lurlher agrees to remove same upon notice Irom the <br />City and i, revlace public pwperty damaged Ihereby. <br />(i - — <br />S� ature ol ApPlican Dale <br />N RK AUTHORI2ED BY THIS PE7MIT MUST BE STARTED WITti1N <br />BO DA1'S OF DATE PERMIT IS ISSUEO AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETI )N. THI� PERMIT !.7AY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE Of WORK ON THIS <br />PFOJECT OVER 90 DAYS DURATION. <br />