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oete `� �a �3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�iG /ti: �� �YS �4 <br />Proposed Work <br />Prolect Address (if known) <br />rs !t <br />Meiling Address <br />� / i,�� ,�- � <br />/U7�L6�c; <br />Ciry �Z�P, <br />/i // <br />City Z�P <br />= �vn i� y �x <br />� � / � � /1 �� <br />/_ . �=,,i��r� � . �,r� <br />L <br />PuElie Woek� Permlt r ��� <br />BiEp. Dept • <br />Puelic Work� Fee s � `O` <br />Toiel Fae <br />Lesa AppL Fee Pe10 = �/ <br />Bsience Due s� � v <br />� !��'/'c'�.1/� <br />�Phone <br />!� <br />� �—� � <br />' s <br />Attach four (4) copias of plens br proposed work • Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline end dimenslons of ell existing and • Indlcate North, <br />proposed structures on the lot • Show eny proposed Brading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrs. in advance - phone 259-8815. <br />2. All work ahell be pertormed in accordence with this permit and current City of Everett Design and Construction <br />Standerds and Specificatlona <br />3. Call Locatlon Underground Service 48 hrs. befo�e you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�E� � b3i9 SD <br />Y G/tTc�� /YiKJ'!— ✓G 4�pPi-vut.� �t,� O�t <br />/ / <br />�Kl��� �it�O�iJ� r.��NY�c�Vb� �/yOr � <br />l� <br />S � <br />��'�, � � <br />c.o Y P <br />l�a�l�V <br />���pr� P�P`� <br />� �� /h5� ��� t( <br />ACKNOWLEDGEMENT OF CONDITIONS <br />-�/�/ �/��/�rws��---- _ 8_ /J�''%r <br />roved for Cons ruction Dete <br />�_if�i/' i/�s � 3 ' <br />FINAL I� NSpE�T�N Date <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Slreet <br />Everett WA 98201 <br />Phone: 259•8815 <br />3 <br />� <br />� <br />� <br />� <br />� <br />a <br />The undersigned ownedapplicent hereby aprees to hoid and seve herm• <br />ess the City ot Evorett from any and all claims for damegea costa, <br />-penses, or causes of action thet mey arise beceuse ot instelletion <br />a d maintenence of the improvement or olher right-ol•way use hereto <br />e plied for and furthar agreas to remove seme upon notice from the <br />ity and to replace public propeAy demeged thereby. <br />l/-�� ��.� 9�/gs <br />Signa�ure of Applicent � �.. Dete <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED W�THIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 9U DAYS DURATION. <br />�J <br />