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Date��z -�'� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Applicanl <br />Describe Proposed Work <br />Mailing <br />� <br />�, <br />cnv <br />. S'= - 6$ <br />� � �- <br />Pu0' c Worhe Fermit a ��'� <br />Biog [�eo�. � <br />FubLc Worka Fee s <br />total fee <br />lesa AOD� Fee Peitl � � <br />Baqnce Due S �" �� � �� <br />7s y`P <br />9 Fl�z�3 <br />Zip <br />Ci�y Zip <br />J <br />Proiect Address (il known� S_30� - LcJ C-�rr�ch,e —__ <br />Attach fow (4) copies oi plans for proposed work • Draw to scale and note the tollowing as appGcable�. <br />• Property Lines • Cemerline ol sireet <br />• Oulline and dimensions of all er.isting and • Indicale North <br />proposed strudures on the �ol • Show any propos�:d �lrading U�,anges <br />• Existing and proposed utiGtles • Show mensurements <br />�S�s -�.5 .:'< <br />PEfildlT CONDITIONS <br />t. All calls for inspection shall be n� e 24 hrs. in advance - nhone 259•881 5. <br />2. All work shall �e perlormed in accordance with ihis permit and current Ciry of Evere• 1 Desiqn and Construction <br />Standards and Specilir,ations. <br />3. Call Location Underground Service 4B hrs. belore you dig. 70LL FREE NUMBER 1-800•4L4-5555. <br />`�1/ l�Jl,'i�"3' ,� �.7' ' b' � <br />Approved lor ConsVvction .� Date <br />i <br />—� i -� ���j��� z ��,-.�- <br />FI L i SPEGTION �� Dale <br />Approved as Cons�ruCted <br />iy.�,�eq PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone: 259-88 I 5 <br />�CHNOWIEJGE1dENT Of CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />� <br />The untla;slgnea �wner/applican� hereby agrees to hold and sav? harm- <br />less Ihe C�ty of Everett Irom any and all claims tor damages, costs, <br />expenses. or causes ol action that may zrise because ol inslallation <br />and ma�ntenance o( thz improvement or olher righbobway use hereto <br />apPlied for and lurther agrees to remo�e :ame upon notice Irom thr. <br />Gty and to replace public properry damaged IhereLy. <br />,, <br />���,� �ii , _ .� .s <br />Signaturc i�canl Date <br />WORK AU O'.� ZED BY THIS PERMIT ML'ST BE STARTED WITHIN <br />1B0 DA'/S Cf G?7E PERMIT IS ISSUED l,NJ THEREAFTEF IS TO <br />BE DIL�GENT�Y PURSUED TO COMPLETION. THIS QERMIT M�Y 8E <br />CANCELLED BY THE CITY UPON AN'( STOPPAGE OF WOqK ON THIS <br />PFOJcCT CJER 90 DAY;; UURATION. <br />�+ �- <br />H4 <br />� �. <br />G`� r <br />�] ' <br />G; <br />� <br />� <br />t" : ' <br />� . <br />1 <br />O <br />.� . <br />.� <br />� <br />� <br />: <br />