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Date��0 � • • P�o�,�wo,wsPa,m��. <br /> Application For <br /> eieg oeo� . t�G�� �L 7.3�a <br /> PUBLIC WORKS PERMIT P�°;o�,F����� S — <br /> �essnooi Fcere�d $ <br /> Print or Type ONy °���°`°r°° $ _ _ <br /> S � ' <br /> �i��.S��,.t �� 3 � ro��u r� /�-L. �1.����_3 s 9 -,/3ti � <br /> Ownrr Mailing AAdress Cdy T_ip Phone <br /> �(a IM�I� <br /> Applicant Mailin9 Address Cily Z�G Phone <br /> Descnbe ProposeA Work ��_ /11 Q��C 1� <br /> ProleCtAddress(ifknownl �7c�� J 1 ]IJJ/-�j,(�_ � <br /> � <br /> Atlach lom(4��opies ol plans lor proposed work- Draw to scale and note the lollowing as apnlicable: � <br /> • ProPerry Lines • Centerline ol stmet � <br /> • Outline and dimensions of all eaisling and i Indicate North <br /> p��posed struclures on th�lot • Show any pwposed grading chanycs <br /> G earsting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELCVJ THIS LINE <br /> PEFiMIT CONDITIONS O <br /> t. All calls for inspection shall be made 24 hrs. in advance- phon�259•881 5. � <br /> 2. All work shall be performed in accordance with this permil and current Ci1y ol Evere:t Dr.sign and Construction <br /> Slantlards and Specilications. <br /> 3. Call Location Undn,rground Service 4B hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. � <br /> P�/l�GiC Lc�OL_',CS �c�/n:% iLiO% iE'.� C�1 U/2E'�7� d?�85� O <br /> / - / � <br /> z/ � <br /> O <br /> a <br /> AC'QJOWLEDGEMENT nF CONDITIONS <br /> 7he undersi9ned o�vneUapplicanl hereby agrees to hold and save harm- <br /> less Ihe City ol C✓eretl irom any and all claims lor damages. cnsts, <br /> expenses, or cau�:es of action that may ar.se because ol installation <br /> and maintenance ol ihe improvement or other righPobway use hereto <br /> Approved lor Constructioo Date applied for and lurther ag�ees to remove same upon no6ce irum Ihe <br /> City and to replace public property damaged �hereby. <br /> FINAL INSPECTION Date <br /> Approeed as Constructed Signature ot Applicant Datc <br /> everelt PUBLIC V✓ORKS DEPARTMFNT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WI iHIN <br /> � 3200 Cedar Street 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIG[NTLV PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone: 259�8015 CANC[LLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />