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-,..�.a_. y <br /> �BtQ�� � PuO�ic WorV Perm� <br /> Application For e�ao oeo�-• <br /> PUBLIC WORKS PERMIT Pu�i�cWorkeFee <br /> TotnlFee f <br /> Lesa�ppl Fee PerE S <br /> Print or Type Only Balencn0�e s <br /> �,�.� �1�� �����2�C�' �Sa -�/.�� <br /> Owner Mailing Address Cit� Zip Phone <br /> .-,L Ne�e�y G,_,JP�e.J�,-���'�.�1��;,� J� �s,r- 73s7 <br /> Apptcant MaJingAdtlress City Zip Phone <br /> / I � <br /> Describe Proposed Work � � �� — �1,/' X�� � �`'�"ti <br /> - W <br /> Prolect Address(if known) � <br /> Attach four(4)copies ot plans lor proposed work-Draw to scale anG note the lollowing as applicable: � <br /> • Property Linas • Centerline ol street � <br /> • Outline and dimensions ot all ezisting and • Indicate Norih <br /> proposed siructures on the lot • Show any proposed grading changes <br /> • Ezisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDIT�ONS O <br /> 1. All calls for inspection shall be made 24 hrs. in advance- phone 259•$$�5. � <br /> 2. All work shall be performed in accordance with Ihis permit and current City of Everetl Design and Consiruction <br /> Standards and Specificetions. <br /> 3. Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•b555. � <br /> �!/.BL/G LvO�'.fS �E.E'iniT if.N�T .f'�9GiiE'E.L��� O <br /> � -��-�6 � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF COND�TIONS <br /> The undersigned owner/applicant hereby agrees to hold and save ha�m� <br /> less the City ol Everetl Irom any antl all claime lor damages. cosis, <br /> expenses, or causes ol action that may arise because ol installation <br /> and maintenance ol Ihe improvement or other right-ol�way use hereto <br /> applied lor and lurther agrees to remove same upon notice f:om Ihe <br /> Approved lor Consiruction Date Cily and to replace public properry damaged thereby. <br /> FINAL INSPECTIOM1 Date <br /> Approved as Constructed Signature of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITNIN <br /> � 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br /> Everett.WA 90207 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8815 CANCELLED BY THE CIN UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURA710N. <br />