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/� � / �� �. <br /> Date�L1- �� Pu�l¢�Voiks Permn a <br /> BIGB DeJt• � � 'C' �/� -' <br /> Application For <br /> PUBLIC WORKS PERMIT PueTolaliaeFee s <br /> Lass Aop�Fee PaiE S <br /> Belance Due s <br /> Print or Type Only <br /> `�-�rn l�l ('� t,c������� ��,-Ir rk��r (�s�r,?, �I�4-��,� <br /> Owner Mailmg Address City Lp Phone <br /> L71n I/1 <br /> � Meilin Address City Zip Phone <br /> Applicant 9 <br /> Deacribe Proposed Work ������� <br /> � <br /> Project Address(if known) �'�� �l��f�� �� � � <br /> Attach four(4)copies of plans for proposed work-Draw to scale and note the following as applicable: � ' <br /> • Property Lines . • Centerline of street � � <br /> • Out�ine and dimensions ol all ezisting and • Indicate North I <br /> proposed struclures on the lot • Show any proposed grading changes � <br /> • Eaisting and proposed u�ilities • Show measurements M <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS I <br /> 1. All calls for inspection shall be made 24 hrs. in advance•phone 259•8815. � <br /> 2. All work shall be performed in accordance with this oermit end current Ciry of Everett Desiyn and ConsVuclion ! <br /> Standards and Specificatfons. � <br /> 3. Call Location Undergrouna Service 48 hrs.befoie you dig.TOLL FREE NUMBER 1-800•424•5555. � ! <br /> � <br /> O I <br /> -i2_��JC-7�� �;C��C�� �'F�I� L � � � ��. � T��_'l.��U��� � . <br /> � .� <br /> .�;.�� � <br /> �,„-�,-- a . <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less ihe Ciry of Everelt Irom any and all claims lor damages, cosis, <br /> expenses, or causes ol action that may arise 6ecause of installation <br /> and maintenance of the improvement or other right-ol-way use hereto <br /> applied for and turiher agrees to remove same upon notice irom the <br /> Approved for Construclion Date City and to replace public property damaged lhereby. <br /> FINAL INSPECTION Date <br /> Approved as Cons�ructed Signature ot Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED Bl' THIS PERMIT MUST BE STARTED WITHIN <br /> 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sireet BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everetl,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-BB15 PROJEGT OVER 90 DAYS DURATION. <br />