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- .J - 19 - 29 - 5�- - / <br />' Date�4� y � v�oi��wo��sa��mn. 9����� s <br /> DiOP oeot..����^. '"'�---�—_—. <br /> AppliCation FOr <br /> PUBLIC WORKS PERMIT Pu�l¢Worksfea _ <br /> ro�a�F�� s <br /> �ess Appl.Fee VrN $ <br /> Balance Due S ��On <br /> Print o�Type Only ,��z-3Z2-/O-00o-:/- g3/ <br /> �, . . <br /> N,��z� Mai4ing Adtlress City 2ip Phone <br /> � �iaia/� 1�c�`aa�/ , 3+�'� 7?P`� <br /> r�r�ti�a,� �-. ��i�,- ���� �,,a <br /> qpplicant Mailing Adaress � Cit �Z p— Phone <br /> Describe Proposed Work !Y� ���� D /� � <br /> — — W <br /> ProiectAddress(ifknownl 23� ������ AVE ~ <br /> Attach four(4)copies of plans lor proposed work- Draw to scale and note the lollowing as apFlicable: � <br /> • Property Lines • CeMerline of sireet � <br /> • Outline and dimensions Of all ezisting and • Intlicate N�rth <br /> proposed structures on the lot • Show acy proposed gratlin9 rhanpes <br /> • Exisling anA Proposed utili�ies • Sl�ow measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LI�IE � <br /> PERMIT CONDITIONS � <br /> 1.AII calis for inspection shall be made 24 hrs.in advance•phone 259•8810. <br /> 2.All work shell be peAormed in accordance with this permit and current City ol Everett Design and Construction <br /> Standerds end Specifications. � <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800-424-5555. <br /> ys� w�� � d� ,�z ���,o�� � <br /> �a-s���,. ��9n, <br /> � <br /> � <br /> 0 <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agmes to hold and save harm• <br /> less ihe City ol Fveret� Irom any and all claims for damages, cosis. <br /> ezpenses, or ca�ses ol action lhat may arise because oi insta��ation <br /> ��/� ,,7p� a _9 �D an ,maintenance of the improvemenl or other ri�hPof•way use hereto <br /> `�Vj/ �j a plied for and furlher agrees to remove same upon notice from ihe <br /> qpproved for Consiructi Date C y and ro replace public ro rty da pgetl thereby. <br /> ��n /!�� /G��'/�'O 1 <br /> / i� CC� ) <br /> FINAL INSPECTION �a�e � Date <br /> Approved as Constructed Signature ol AP iicant <br /> WORK AUTHORIZED 8Y THIS PERMIT MUST BE STARiED WITHIN <br /> eeerett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMii IS ISSUED AND THEREAFiER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everet4�"1A98207 CANCELLED 8Y THE CITY UPON ANY STOPPAGE OF WORK ON TNIS <br /> Phone:259�BB10 PFOJECT OVER 90 DAYS DURATIOIJ. <br />