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Da(e� � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Describe Proposed Work <br />Prolect Add�eso (if known) <br />ng <br />-�in*h <br />Mailing Address <br />City <br />.-, ^, ,-� <br />PubliC WO1M5 Pefm�� � `^ � / t <br />o�aA oeo�.. ir�9 %�� �Z— <br />Puol¢ Ivoihs Fro <br />,a�a� F�� s <br />�ess noo� Fee Paio S ^� <br />o.�iance Owr S � <br />a -r;3 �/ <br />Zip � Phone <br />Attach four (4) copies ol plans lor proposed work • Draw to scale and note Ihe lollowing as applicable: <br />• Property Lines <br />• Outline and dimensions ol all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />• Centerline ol sireel <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall6e made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be performed in accordance with this permit and current City ol Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424•5555. <br />� L-,C��s: i,vlr Cu/'B/ Gur2=�� /I.c�i) S! i�E�v/'t! %a 6�: <br />C'O/'�i'L.FTEc.�/ �-�E�'%'O vG0 , <br />� /J%f�C�ts I%.�/L�iiltJ.'9� .�'�F�C�.S /.�-'C.�e?,r/�i`%'. TN'S'i�GC ��Tti <br />L/ Ty ciiRnJDf,'i'O ff,� O% <br />' >%'i��,-r! 5{ /�;/�s <br />Approved lor Constr � n � / Date <br />_ / Q G•2-�i <br />FINAL INSPECTION Date <br />Approved as Construcled <br />Pverett PUBLIC WORKS DEPAR7MEN7 <br />� 3200 Cedar Slreet <br />Everell, WA 98201 <br />Phone: 259�BB10 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersigned owner/appliwot hereUy agrees to hold and save harm� <br />less ihe Ci�y of Everelt irom any and all claims �or damages, costs, ', <br />expenses, or causes of action ihat may arise because of installation � <br />and maintenance ol the improvement or other right-obway use hereto <br />applied for and further agrees to remove same upon notice Irom the . <br />Ciry and to replace public property damaged thereby. <br />�//i�-��� � <br />�Z— ��' <br />ign ture ol Applicant Datc <br />WORK AUTIIORIZ[D BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSIIED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ I <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS � <br />PROJECT OVER 90 DAYS DURATION. � <br />