Laserfiche WebLink
Date � f� �� � <br />PUBLIC <br />Print or Type Only <br />.-� <br />l�G.<In',�-i��� �✓r ci: � <br />Owner <br />� <br />« <br />Application Fo� <br />WORK� PERMIT <br />� On S <br />In N N <br />M <br />�n w <br />.y <br />�a�=�- . US'� � ot,�� <br />Mailing A�re s.. `�C'j � <br />r �. �� <br />' avTc�,Y! <br />+�_ii'.:- ��'..�.�i,:– .�i.- l�. <br />Mailing Address <br />�}� � <br />Pvn��,c Works Permit � _' �,J "�- / _ <br />Blaa �ept • <br />Pu�Lp N'orks Fae <br />Total Fee S <br />Less AOVI. Foe Pai� � <br />^�« <br />0o�ance Due S "x'-J _ <br />Zip Phone <br />7�L� - �; <br />Phone <br />Describe Proposed Work `��-� �� h%�=`s �� j�i �–.'�'i�� /�rF� f?R'�'i_l4Tf <br />f�d�J /IGn,�I– C.r�i ii ic��ir– l'F– Lr��/.. <br />Proiect dddress (it known) �%L/Jl/i-1 T� %ii/ �It-!". — Si'� !T// CF 5��`'SY.' <br />Attach lour (4) copies ol plans for proposed work - Draw to scale and note the following as applicable: <br />• Properly Lines <br />• Outline and dimensions ol all existing and <br />propc�ed structures on the lot <br />• Ezisting and proposed utilitie= <br />PERMIT CONDITIONS <br />� <br />• Centerline of sireet <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measurements <br />1. All calls for inspeclion shall be made 24 hrs. in advance - phone 259�881 5. <br />2. All work shall be performed in accordance with ihis permil and cmrent City of Everett Design and Construction <br />3tandards and Specifications. <br />3. Call �ocation Underground Service 48 hrs. before you dig. TOLL FREE NUMBcR 1-800•424•5555. <br />;, �1'0�>',1��/ �;up SEiJi„>in'T-?rt>iV �oi!ri't�L �i.� ii�is <br />.SiTF �c f+F /�ln�F .•�S i.>�.!Fli=-i> /�f/ %/c /��i��il� <br />�r 'Y:�'.�S %R:Ti-'_F�7��.C' <br />�` �.��s�;�-.--/�-__ /,���4� <br />Approved tor Consiruction // a�e <br />' �ucr.""' 'o..l Y�G'P <br />F�FECTION Date <br />Approved as Construc!ed <br />everett FUBL�C WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Plionr.:25S-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned own=r/applicant hereby agrees to hold and save harm- <br />less the City of [verelt Irom any and all claims for damages, cosis, <br />expenses, or causes of action that may arise because of installation <br />and maiNenance of ihe improvement or other righbof-way use hereto <br />applied for and further agrees t� remuve same upon notice irom the <br />Q`i�and- replace public propeny damaged Ihereby. <br />� ��f�� l ' � � .p.'ts �L'L �G' . /L�_ � S <br />Signature ol ApPlicant Uate <br />WORK AUTH7RIZFD BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND TIiEREAFTEP IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCEI�ED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJEGT OVER 90 DAYS DURATION. _./ <br />