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Date /6'G <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Publ-d Ill Permit • c b — / 113 <br />Bldg peor e <br />Lc it Fee <br />totes Fee { <br />Leee APPI Fee Perd { <br />aelenoe Dve { 8 <br />Malting <br />E>'iL.t <br />Owner Address <br />City Zip Phone <br />.5y' 0 2- 4 4'r ktP fil <br />/ lip I J 3s <br />Applicant Mailing gtldress City Zip Phone <br />�/C� +/ems c <br />Lescribe Proposed Work c %'/ri2 ,rr=w/y —�� <br />LU <br />Project Address lit known) ✓ ' — ZfJ- T2�O,- F <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and • Centerline of street <br />• Indicate North <br />CIO <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />DO NOT <br />WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />O <br />1. All calls for inspection shall be made 24 hrsin advance - phone 259.8131 5. <br />2. All work shall be Performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />1♦♦"ww� <br />V♦ <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm. <br />less the City of Everett from any and all claims for damages, costs, <br />rglc expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />:A:��rbvecd for nstru applied for and further agrees to remove same upon notice from the <br />City and to replacepublic property damFAL INSPECTION E b ICJ-��n4 Approved as Constructed Date Signature of Applicant Date <br />ieverett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />Everett, WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BEPhone: 259-8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />