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� <br /> Date ^ �•„���,�.w�,.,�-., . � <br /> APPlicxtion For u�aa ocn�.• <br /> PUBLIC WORKS PERMIT �'������cwmke�ae - <br /> .a���.�P �— <br /> LeasFopl FeePxiJ S <br /> Oxdnce Dm t <br /> Print or Type Only <br /> �i1�► m � f�n14 ��S 51 LJ �g l� )ti l,(h,r� �.� <br /> Owner Ma AJdress City Lp Phone <br /> �F�F:� C� ��7 )Qi l� <br /> Applicent Mallmg Addicss Cny Zip Phone <br /> Oescribe P�oposed Work �'[ �u��lJl� <br /> W <br /> Prolect AdCress lil knownl _ � <br /> Attach lour�4)cop�es o�p�ans br proposed wo�k- Diaw to swle and oo e following as applicable: � <br /> • P�operry Lines • Centerline of slreel � <br /> • Outline and dimensions ol all ezisting and • Indicate North <br /> proposed structures on the lot • Show any propo=etl grading changes <br /> • Existing and proposed utilities • Show measuiements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All cells for inspection sha�l bo made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shail be pedormed in accordance wit1�ihis permit and curreM City of Everett Design and Construction <br /> Stendarda and Specifitetions. <br /> 3.Call Location Underg.ound Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> ` <br /> �UBL/G Gl�d',e.PS' f'�s�E%�7i% �Oi i?�s'-�U/.1.FD ���8 O <br /> J � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF GONDITIONS <br /> ihe undersigneA owner/applicant hereby agrees to hold and save harm- <br /> less the City ol Everett irom any and all claims fa damages, costs. <br /> expenses, or causes ol action that may arise because of installation <br /> and ma ntenance ol Ihe improvement or other right�of-way use hereto <br /> _ applied lor and lurlher agrees to remove same upon noUce Irom ihe <br /> Approved br Construction Date C�ry and m replace public property damaged thereby. <br /> FINAL INSPECTION Date -- <br /> Approved as Construded SignaWre of Applicant Dale <br /> WORK AUTHORIZCD OY THIS PERMIT MUST BE STARTED WITHIN <br /> evrrett PUBLIGWGRKSDEPARTMENi 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarSireet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everell.WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phonc:259�8870 PROJ[CT OVLR 90 DAVS DURA^ON. <br />