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N�l�Fcv�1;� �2t�>T/u/�-�'i�"t��'� �rs� .�'f fi/��Es�m <br /> _ ' " ��/ � PUCIic Wo�k�Permll• <br /> Da:e sma o�o+.• <br /> Application For <br /> PUBLIC WORKS PERMIT P"°"""°""°° <br /> To1ai Poe f <br /> Less ADG�Fee Pa�E s <br /> Balantt Uue s <br /> Print or Type Only <br /> ` Cl t n— . ' ` � �A.LC� V'J^:- ��.�, <br /> Ir � ��tl.�t���V l�lLt1C �— �C� Lv 'th�16�� C,�..` �U Phone <br /> .1.. {�1�4�� C.. Y 2ip <br /> Owner �Mailing Ad ess C�� <br /> /� � " � 'l�1 �i 7t'f1� 1 f`l�t LK �S���Kv\S (i �f�l � '�� -•i�14- S <br /> i2�i ` T ���[�� v��P'. ) /1'7 Z� Phone <br /> � Mailing Addres�s L LzC�ity _ l / <br /> ppplicant f d LU// � .Gci./d�ny �r:MOC�.". G <br /> T/I CO✓1Tll/7G / C1 � <br /> �_ ' 1- - : - - ,t � c�= �� �c� <br /> �escribe Proposed Wor �-� � <br /> St� C'�v,���r �'�, <br /> c1� •d, � s � L <br /> � � <br /> -� -r ' ��- '�;r i � � <br /> � � _ , , ; �c, l' ic ' �a <br /> _�� i; _ � � <br /> Prolect Address(if known) — <br /> Attach four�4) copies ol plans for proposed work- Draw to scale and note the tollowing as applicable: � <br /> • Property Lines • Centerline of streel <br /> • lodicate North <br /> • Outline and dimensions ol all ezistinq and � Show any proposed grading changes <br /> proposed structures on the lot � Show measurements M <br /> • Ezisting and proposed ulili�ies W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> 1.All calls for inspection shall be made 24 hrs.in advance•phone 259•8810. <br /> 2,All work shall be peAormed in accordance with lhis permit and current City ot Everett Design and Construction <br /> Standards and Specifications. � <br /> 3.Call Localion Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•555 . <br /> � - �y:�a /�iG!/zl�—C� O <br /> /-.���� �� �� � <br /> //�� ( �'� C�i-"fi-nar� CY� i� r e a� \ �A <br /> T�� �'��s..J � BUi�c�inyJ V� <br /> � �ar Utc a5 Loa�/vnLvac� -�'P2c2 i' O <br /> ��.p�CefcG� f�/Yl�i t✓ay <br /> `,�a ��3 -�� a <br /> ww�w � - . <br /> �� ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees lo hold and save harm� <br /> less Ihe City o1 Everett Irom any and all claims for damages, costs. <br /> expenses, or causes of aclion ihal may arise because of installation <br /> antl maintenance ot ihe improvemenl or other rigM-oFway use hereto <br /> applied lor and turther agrees lo remove same upon notice from the <br /> Approved for Canstruction <br /> Date Cily and to rep�ace public property damaged ihereby. <br /> t <br /> Date � • ----- - ate <br /> FINAL INSPEGTION Siynature of Aoplicant <br /> Approved as Constructed WpRK AUTHORI2ED BY THIS PERMIT MUST BE STARTED N.'�7HIN <br /> PU�LIC WORKS OEPARTMENT BE DI�LIGENOTLY PURSUED TOICOMPLEDTION.DTH S PERMIT MAY �E <br /> ������ 3200 Cedar Street <br /> Everett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON TNIS <br /> Phone:259�3810 PROJECT OVER 90 DAYS DURATION. <br />