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_ , <br /> r <br /> � <br /> r <br /> Z <br /> g3 in L <br /> rumm wor�e Pe�mn. <br /> 'J�'�V=�3 eiaa oco+.. " — <br /> Date_ <br /> qpplicalion Fo� <br /> PERMIT P"'°`""°`""" - <br /> PUBLIC WORKS '°'°"" S '-= <br /> LossAro�PoePe�e � <br /> ^ aalen_e Oua s ^�^ � <br /> ! <br /> Print or Type Only � <br /> / i L Sciyhc�'sl Ld�[:_>%I �i .��-Z -.�-���, <br /> � 1 m "��'���' �` ^1 � <br /> '� , `L . ./�� i CitY Zip Phone <br /> Ow�ef Meiling Address <br /> r„ ` j� _�e�lr ns `i fi.% sJ ? 3' -`i%E_ <br /> /%,'f,�til� �T.��,-., -��_ �5 7 - ��q in�c .r Z�p Phone <br /> qpplicant <br /> Mailing Address ���Y <br /> ��> jHc?�I� C`'.Nt�r/r,�=- <br /> pescribe Proposed Work _ <br /> W <br /> �15 .?�l S�ra/�-�. 7 :o�« -T �" <br /> Project Address(il known) � <br /> Attach four(4)copies ol plans for proposed work-Oraw to scale and note�Ge°�terline ol sUee�able: � <br /> • Property Lines • Indicate Norih <br /> •Outline and dimensions o�all eaisting and � ghuw any P�oposed grading changes � <br /> proposed strudures on the lot � ghow measuremenis <br /> • Exisling and praposed utilities <br /> DO NOT WRITE BELOW THIS LINE o <br /> pcqM1T CONDITIONS � <br /> 1. All calls tor Inspection shall be matle 24 hrs. in advance-phone 259•881 5. <br /> 2. All work shall be periormed in accordance with Ihis permi�and current Gity of Everett Design and Conslmction � <br /> Standerds and Specilications <br /> 3. Call Location Unde�ground Se���ce 48 hrs.belore you d�g.TOLL FREE NUMBER 1'800•424-55 • <br /> O <br /> � <br /> N <br /> O <br /> a <br /> ACKNOWLEDGEMcNT OF GONDITIONS <br /> The undersigned owner/applicant hereUy agrees to hold and save harm- <br /> less the City of Everetl Irom any and all claims for damages, costs, <br /> ezpenses. or causes ol action that may arise because ol installation <br /> and maintennnce ol the improvement or other righl-of�way use hereto <br /> • / �=/l -�3 �PP11ed fOr and luriher agrees �o remove same upon notice irom the <br /> oved�or Constructio Date City and to replace pu6lic p pe�rry damaged lhereby. <br /> � ��.� � y��C-�� � ' � J <br /> Dale Datc <br /> F L INSPECTION i lure of APPlican <br /> ApD�o�edasConslructed WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMEN7 180 DAYS OF UATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 0 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> E�eretl,WA 9820� CANCELLED OV THE CITV UPON ANY STOPPAGE OF WORK ON TMIS <br /> Phone:259�8815 PROJECT OVER 90 DAYS DURATION. � <br /> � <br /> L <br /> J <br />