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Date�y;.�� � Q <br /> APPlication�r Tn P�STING �Ci Q 1 2�� P�oncworx�Per �5/ <br /> ema oeo� � <br /> PUBLIC WOR �I�S PERMIT P���KW�«.F« , -- <br /> Q Totnl Fee <br /> O <br /> O� leas�no� �ee PniE S <br /> Print or Type Only ¢ � '�.' i.'Oo ea�a�«n�s s S 77�--� <br /> m � r � � 1 � 14•sNN� <br /> �j ♦/� O p a .7 M <br /> wner ,!�,d._..� ��`�• l �-+'�'-`� �PQ�ry�!� (,lL,I <br /> , � MaiNn�Adifr� � i c�a C�ty ,Z`p ( )��II/Y l� <br /> `�.T�u�►����+����� '�i�r st ����C',C� �a <br /> Apphcant MailinqAdtlress Gty ZiP D���� <br /> �'7�` , /� OC. <br /> Descrlbe Proposed Work I�V'�/ '�� <br /> Pro�ect Adtlress pf known) 820- LdA�FSPl sl A//� � <br /> i � <br /> Attach four�4)copies ol plans for propose.d work• Draw to scale and note the lollowin�as applicable: _ <br /> � Property Lines • Centerline of street � <br /> • Outline and dimension>of all existing and • Indicate North <br /> proposeA structures on Ihe lol • Show any proposed gratling changes <br /> • EMisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW TffIS LINE <br /> � PERMITCONDITIONS O <br /> 1.All calls(or inspection shall be mxde 24 hrs.in advance•phcne 259�8810. � . <br /> � 2.All wo�k shall be pertormed in accordance with this permit and current City of Everett Design and Construcfion <br /> Standards antl Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800-424•SSSS. � . <br /> T. �vz�,. - .�O lze. do�.� ,� ,o.�� a�,o,� O <br /> ' � � P.�.e� ��. d�f � 9�� g� . �LoPy A�119cHED� <br /> � � , <br /> -�� ! "f.([ >i:..- .��7 j7.o�'r-�n.'o Si'��GrS G-ls�r�%H.£i�T D.✓ 19n.�t-S O <br /> i�i-",.' SY�f,-�q C /���i'F��7� C �J_F PF.�.�inii. � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant here6y agrees to hold end save harm• <br /> less ihe City ol Everett irom any and atl claims for Aamages, costs, <br /> expenses, or causes of action that may arise because ol inslallation <br /> � �, �Q� and maintenance of the improvement or othe� right�of-way use hereto <br /> APA� ed for nstru I apnlied lor and �urther agrees to remove same upon notice Irom the <br /> / �/ � , a� Ciiy and to re lace pubGc property damaged thereby. <br /> � 3�T- 5v Q � <br /> FINAL INSPECTION pa1e C�Z� �� <br /> Approved as Constructed ure M Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 3200CedarSireet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 99201 BE �ILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone:259-8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON TMIS <br /> PROJECT OVER 90 DAYS DURATION. <br />