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Date�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />I 7J a /�.l.t� <br />Mailing Address <br />c�cv <br />S <br />Pu011e Work� Po 11 • 5 ZJ <br />eiao.o•o� • S / 0 <br />PUEiic Work� F�a <br />Tal�l Fse s <br />Less �ppl Fea P�10 s <br />etl�nceoue f �9���� <br />%S.3o�7 <br />�iv7 7F9- ��5 <br />Phona <br />/l�/ ��3 - �3�� <br />Describe Proposed Work �'-�a i� ls� U�-c <br />Pro�ect Address (il known) Q ()� � <br />Attech four (4) copies of plans for proposed work • Draw to scale and note the lollowing as applicable: � <br />• P�operty Lines • Centerline ol streel � <br />• Outline and dimensions of ell existing and • Indicate North <br />proposed structures on the lot • Show any preposed grading changes <br />• Existing end proposed uti�ities • Show measurements ��e <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All work shell be performed in acco�dance with ihis permit and current City ol Everett Design and Construclion <br />Standards and Specilications. <br />3. Cell Location Underground Service 48 hrs. betore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�j�, %O 6'E� C�G/1/S7i4'UGTE/% /��E.'� /�C/JNS <br />//9/•S'S . <br />��A� �����_ <br />L F �l / <br />Approved lor Cons ru ion Date <br />/�i%�l� ��.t 3 .F1� <br />Ftl AL INSPECTION ' Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Ceder Sireet <br />Everett, WA 98201 <br />Phone: 259�8875 <br />Aff'.Bo vE/� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />O <br />� <br />The undersigned owner/applicant heroby agroes to hold antl seve harm• <br />less thr, City ol Everetl Irom any and all clnims lor tlamegea, coet0. <br />expenses, o� causes ol action that may arisa because ol Inetallallon <br />and m. inlenance ol Ihe improvemenl or other righl•ol•way usa herato <br />applied lor and lurther agrees to remove same upon notice Irom the <br />Ciry and b replaca public propr.rty dnmegod Ihureby, <br />� L �,.� (� �-e-Z 2 -1 z - � �" <br />Signa�ure ol Applicont Dnto <br />WORK AUTHORIZED BY THIS PERMIT MUST BE S7ARTED WITNIN <br />180 DAYS OF DATE PERMIT IS ISSUED hND THEREAFTER IS 70 <br />BE DILIGENfLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITV UPON ANY STOPPAGE OF NIORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />