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Dat�G��g <br />Application Fof <br />PUBLIC W4RKS PERMIT <br />Print or Type Only <br />Applicant <br />Describe Prof�sed Work <br />v�L(�?C-rE <br />`/�., fi�'ar TJk' d%i!1 l <br />Mailing Address City <br />�Q �sSC �J ( O 7 �7a�� <br />Mailing Address � Ci�y <br />Project Address (il know�) 70 2 5- <br />Pu�Lc Warxs Perm�t •(� �� �' ✓ � <br />eiaq Dani� • _CT � /�� D3 k � <br />Popt¢ Workg Fce <br />Total Fce $ <br />LC55 Rtpl Fee PaN S .�7 <br />Baiance0ue S G�— <br />Zip Phone <br />Attach four (4) copies ol plans lor „roposed work - Draw to scale and note Ihe lollowin9 as applicable: <br />• Property Lines • Centerline of sireet <br />• Outline and dimensions ot all existing and • Indicale Nor�h <br />proposed siructures on lhe lot • Show any proposed gradinc� changes <br />• Existing and proposed ulilities • Show measurements <br />PERMIT CONDITIONS <br />1. All cells for inspection chall be m2de 24 hrs. in advance • phone 259•?R70. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underyround Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800-424•5555. <br />��!/�I� ' <br />� ' J' C� "_u 7� c� cJ�.� <br />Approved for nstructi -n � — � a�e <br />� / , __ � % rf/ <br />FINAL INSPECTION � � r. Date <br />Approved as Consirucled <br />everetl PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everell, WA 98201 <br />Phoiie: 259�BB70 <br />ACKNOWLEDGEIdtM1T OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />L J <br />� <br />� <br />O <br />a <br />The undersigned owneqapplicr�.at he�. ahy ac�rees to hold and sare harm� <br />less the City ol Everett irom nny and all claims lor damac�es, costs, <br />ezpenses, or causes of adior. 7hat may arise because of installation <br />and maintenance ol Ihe improvement or other rlght-ol-way use hereto <br />applied lor and furiher agrees lo remove same upon notice trom the <br />C�ty and to replace public properry dama9ed thereby. <br />�' ��� � <br />�6ignature of Ap --� <br />WORK AUTIiOR12ED BY THIS PERA"IT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENT�Y PURSUED TO COMPLETION. THIS PERMIT h1AY BE <br />CANCELIED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />