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Date��� ~ ���,���wo,.,v.,m <br /> Application For nmp oeo� • <br /> PUBLIC WORKS PERMiT ����°��°°,°��,�°° - <br /> Te�,����a s <br /> lese�r,m rxe Px�a S_ <br /> papno�0un S <br /> Print or Type Only — <br /> ��� <br /> �wner Mailing Atltlress Cdy Zin Phone <br /> Applicant Mailing Address Cny Zip Pl�one <br /> Describe Proposed Work ��' GJ �� c !-!�" v� J�` �' • �" <br /> W <br /> Project Adtlress lil knowN �/ " -- � <br /> Attach four(4)copies ol plans for proposed work� Draw to scale and no�e Ihe lollowing as applicable: � <br /> • Property Lmes • Centedine ot street � <br /> • Outline and dimensions of all e�isting and • Indicate North <br /> proposed structures on the lot • Show any proposed yratling changes <br /> • Ezisting and proposed utilitles • Show measurements � <br /> DO NOT WRITE BFLOW TH�S LINE • O <br /> PERMIT CONDITIONS <br /> 1.All cells lor inspection shall be mede 24 hrs.in advance-phone 259•8870. � <br /> 2.All work shell be peAormed in accordance wilh ihis permit and current City ol Everett Design and Consiruction <br /> Standerds and Specifications. � <br /> 3.Cel!Location Underground Service 48 hrs.before you dlg.TOLL FREE NUMSER 1-800•424•5555. � <br /> /r�� ',,� � O <br /> �'�` �� I- <br /> �r��-��B � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONUITIONS <br /> The undersigned owner/applicant hereby ayrees to hold and save harm- <br /> less Ihe City of Everett irom any and all claims for damages. costs, <br /> ezpenses, or causes ol action that may arise because of installa�ion <br /> ' and mainlenance ol Ihe improvement or other righbol-way use hereto <br /> applied lor and lurther agrees to remove same upon notice from the <br /> A�proved lor Construction Date City and to replace pubhc proPerry damaged Ihereby. <br /> FINAL INSPEC710N Date Date <br /> Approved as Constructed Signatwe ol Applicant <br /> WORK AUTIiOR12ED BY THIS PERMIT MUST BF STAFTED WI�IIiIN <br /> everetl PUBLICWORKSDEPA!iTMEN7 1B0 DAYS OF DATE PERMI7 IS ISSUED AND tHEREAFTER IS TO <br /> � 3200 CeEar Street BE DILIGENTLY PURSUED TO COMPLETION. TH�S PERMIT MAY BE <br /> Everett,WA9B201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PhonE:259�d810 PROJECT OVER 90 DAYS DURATION. <br />