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� <br />Date � - Z�- ��� <br />0 <br />PU�'LIC <br />O <br />O <br />O <br />Print or Type Only� <br />� <br />i�? ,,. <br />Applical'on For <br />WORKS PERMIT <br />O O U <br />wi�' a <br />w w <br />�, ;��5��= C�vl ���. OI, <br />mg Addr 5 CitY ZiP <br />-�—w <br />� o = <br />w��E�C�fz� t4V� #�2100 �x�i <br />Ma�linq A�!dress City Zip <br />✓ <br />Pu�Im Wa .a Perm�it • �/�� <br />B�ao� DeO�- • <br />Publ¢ IYorb Lee s <br />Totel Fee <br />Less Apol Fee Paia S <br />BalenceDue S � <br />Describe Propesed Work G�L �'z'Jst} f iL�Ia� '�Z� S <br />N v- U2,c� o � tiK�, o c= �-or <br />Project Address (il known) <br />�J <br />1�1 <br />Attach four (4) copies of plans lor proposed work � Draw lo scale and note ihe bllowing as applicable: <br />• Property Lines <br />• Outline and dimensions ot all eaisting antl <br />propo5ed 5tructures on the lot <br />• Existing and proposed utilities <br />• Centerline ot street <br />• Inmcale Noith <br />• Show any prcposeJ grading changes <br />• She�v mezsurements <br />Phone <br />Pho <br />�f -o33a <br />PERMIT CONDITIONS <br />1. All ca�ls tor inspection shall be made 24 hrs. in ativanre • phone 259-8810. <br />2. All work shell be peAormed in accordance with this permit antl current:.ity of Everett Design and Conslruction <br />Stand�rds and Specifications. <br />3. Cell Location Underground Service 4B hrs. befor� you dig. TOLL FREE NUMBER 1•800-424•5555. <br />�� �: � I O� cAN`�S L. �� SEp � 1-t CT1 �-Cl o(� Lc�Mtz� l� <br />t"�fL- �li�t.S a 1T€ -Rl BFf�ot�1� �S F�"z- �c�gL�L c,.90i� <br />� �J�P�z-rozs P � ekG'r-co� <br />-t'��Q Wi ��_ (�o -27-9� <br />Approved for Construc � n � Date <br />c %/ <br />��l-�/� � /� �o <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLICWOFKSDEPARTMENT <br />� 3200CedarStreet <br />Everett, WA 98201 <br />Phone:259�0870 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />�/ <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less ihe City of Everett irom any and all claims for damages. costs, <br />expenses, or causes of action that may arise because of ins�a�lation <br />and maintenance ot Ihe improvement or other right�ol-way use hereto <br />applied for nnd lunher agrees to remove same upon notice irom the <br />City and to replace public property damayed ihereby. <br />� <br />•,� <br />SignaWre of Applicant ��� Date <br />WORK AUTHORIZED BY THIS PERMIT MUST DE STAR7ED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPIETION. THIS PEFMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURA?ION. <br />