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Pu�hc WoiMSPurmit< <br /> �3 /73 <br /> Date <br /> eiaa oeo��• <br /> Application For <br /> PUBLIC WORKS PERMIT 7u0t¢Wo�xsPoe � o.oa <br /> To�a�Fed S <br /> � <br /> Less AnP��fee Peia S <br /> oaiance0ue _����'��� <br /> Print or Type Only 6' SI�SvZ <br /> � I��ll y��� /�T����'ll��l9i� ����� GJP�'M�re Hl�P GI�CrP ll /�<()� � J�-a�lY� l <br /> Owner <br /> Mailing Address Cdy Zip Phone <br /> � �� MailingAddress City Zip Phone <br /> ApDlicant <br /> Describe Proposed Work <br /> /S� 3G C+av'aq�e /�crL�-� t�--^� � — <br /> W <br /> Project Address(if known) <br /> y '-� �� : �Y vic ere � <br /> � <br /> Attach four(4)copies ol plans tor proposed work- Draw lo scale and note ihe following as applicable: � <br /> • Property Lines • Centerline ot street <br /> • Outline and dimensions of all ezisting and • Indicate North <br /> proposed structures on Ihe lot • Show any proposed grading changes � <br /> • Existing and proposed utilities • Show measurements <br /> DO NOT WRITE BELOW THIS LINE O <br /> PEFMIT CONDITIONS � <br /> 1. All calls for inspection shall be made 24 hrs.in advance- phone 2b9•88�5. <br /> 2, All work shall be pertormed in accordance with ihis permit and current City ol Everelt Design and Construction <br /> Standards and Specitications. � <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMHER 1•800•a24•5555. <br /> O <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The und�:rsigned owneUapplicant hereby agrees lo hold and save harm- <br /> less ihz City of EvereU Irom any and all claims lor damages, cosls, <br /> expe��ses, or causes oi action thal may arise because ol installation <br /> _�� p3 and maintenance of Ihe improvement or olher rigM-ot�way use hereto <br /> � applied lor and lurlher agrees to remove same upon notice irom the <br /> pproved tor Construction Date City and to replace public property damaged �hereby. <br /> � �/ y? � � � <br /> `�/�--�/���' ��� f- <br /> � Dale �� � <br /> FINAL INSPECTION Signature ol pplicant � e <br /> Approved as Constructed <br /> WORK AUTHORI2CD BY THIS PE IT MUST BE STARTED WITH <br /> everett PUBLIC WORKS DEPAR?MENT 180 DAYS OF DATE PERMIT IS I SUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sireel OE DILIGENTLY PURSUED TO COMPL[TION. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-BB15 PROJECT OV[R 90 DAYS DURATION. <br />