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Date y� <br /> vuebcwodaPermu• 9z/� <br /> Application For eiaa�o�o�-•_ <br /> PUBLIC WQRKS PERMIT PubToelFaeFee : zo <br /> Lesa AOPI.Fee PeiE s <br /> Print or Type Only esia�ce o�e S Z�—_ <br /> WILLIAM RUCKER 2721 f1ETMORE Al'ENUE EVERETi� WA 98201 206-388-8318 <br /> Owner Mailing Address City Zip Phone <br /> cvs nnnvv <br /> Applicant Mailing Atldress City Zip Phone <br /> Describe Proposed Work c:raao and �itt damaQed roadway at end of Sevenich Drive as per e�closed plan. <br /> -��_` c�t-'�T O/� Gi7 Z/�� �� <br /> ��< <� W <br /> ProjectAddress�ilknown) 3 XX S ven:ch Diive� Sverett, Washington r � <br /> Attach four(4�copies of plans��posed work- Draw to sc�le and note Ihe lollowing as applicable: '/6�� ���� � <br /> • Property Lines • Centerline of street � <br /> • Outline and dimensions of all ezisting and • InCicate Nurih <br /> proposed structures on the lo� • Show any proposed grading changes <br /> • , • Existing and proposed utilities • Show measurements � <br /> ' DO N07 WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1.All calis for inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shall be pertormed in accordance with this permit and current City of Everett Desi{7n and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hre.before you dig.TOLL FNEE NUMBER 1•800•424•5555. � <br /> y`.� Sc<2%JscH v�?i�� w��< �r ��- � <br /> /�'i9'rVTi�isJ� � T/�r Cirf�/ivbT Fv� <br /> /'�G/,B</C� GfS�> �iiT oN<y T�- Sr�!/`- � <br /> T'6r�oC�, S_ F.- �d�i�/c G�/.t�G S/TC'�'', � <br /> �S, h�o Ld �/�.�'-/�fGc�l' � ��'� �c co,Gz''�� ' O <br /> ���,�sT �,�o���y .s-�.��. 0. <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> _ The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the Ciry ol Everett Irom any and all claims for damages. cosis. <br /> �� / ezpenses, or causes ot adion that may arise because ol installa�ion <br /> �� �����[� L. and maintenance of ihe improvemenl or other right�of-way use hereto <br /> rl �" applied for and Iwiher agrees lo remove same upon notice from ihe <br /> Approve ) r Construc ion D� e ity and to replace public property damaged ihereby. <br /> � G , � <br /> ��l.c�— .z�3 <br /> FiNAL INSPECTION Date �«�.-✓� i2� Z'3• �i .Z <br /> Approved as Constructed Signature of Applicant Date <br /> PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS i0 <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAV BE <br /> Phone:259-8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF 1VORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />