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^ r <br /> � Date �5� � •.,���,�v,o,.,N�,m��. __ (l� <br /> Application For Hi�p Dept . _��_pZ.p�c+�(.�7 <br /> PUBLIC WORKS PERMIT °°°°°W°,"`°� - -- <br /> ro�.��e� s-- <br /> �essnnni r.evam S <br /> e.,�a����o„� S <br /> Print or Type Only <br /> I� T CUuJG 1L-GJ �1 (�/Q1PH S�'f �uAi/� <br /> Owner Madmg Atldress Gly Lp Phone <br /> / �,�� �{- /Q/CJ-4�Pnu� ,Ar- S.�o(io.�u�/,�)i� �v��'a4►,Y�' <br /> �APPlicant Maihng Address City ZiP Phone <br /> � Describe Proposed Work ��.L' ` ��� � I���A � MI ��,f�('���([� <br /> � W <br /> Project Aadress Iil known� ((1—�-� �e�,L---�� � <br /> Attach lour�4)copies of plans for proposed work- Draw to scale and nole Ihe following as applicable: � <br /> • Property Lines • Centeriine ol slreel � <br /> � � Outline and dimensions ol all existing anA • Indicate North <br /> proposed structures on the lol • Show any proposed graGing changes <br /> , • Exief��iy and proposed utilities • Show measurement, � <br /> � DO NOT WRITE BELOW THIS LINE O <br /> ' PERMIT CONDITIONS <br /> � 1.All cells tor inspection shall be mede 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shail be peAormed in accordance with this permil and current City of Everett Design end Construction <br /> Stendards end Specilications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800-�,�24•5555. � <br /> O <br /> /—�i." ��"i'irii /C OT /_',E��l�i'Q D � <br /> ����.��--� <br /> s�,��� N <br /> O <br /> a <br /> Af,KNOWLEDGEMENT OF CONDITIONS <br /> The unCersigned owner/apPlicant hereby agrees to hold and save harm� <br /> less the Cily ol Everett Irom any and all claims lor damages, costs, <br /> e.penses. or causes ol action ihat may arise because of instal�ation <br /> and maintenance of ihe impwvemenl or other ri9hPof-way use herelo <br /> apPlied lor and lurther agrees to remove same uUon notice trom ihe <br /> Approved for Construction �a�e City and to replace pubhc property damageA ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature of Applicant Date <br /> WORK AUTHORIZED `�Y THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPARtMENT 1g0 DAYS Of DATE PERMIT IS ISSUED AND THERFAFTER IS TO <br /> � 3200CetlarStreet BE DILiGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett.WA 99201 CANCELLED BV THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURATION. <br />