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0 v rWti <br /> �8t@� �� PUEI¢Wo�ha Permil• <br /> AppliCetiOn FOf � Bma.Dept.s �,����Q <br /> T— <br /> PUBLIC WORKS PERMIT PuDI�cWorFSFee s — <br /> Totel Fee <br /> Lcaf�Dol Fae PeIA S <br /> Print or Type Only Ba�a�=�o�� s <br /> S�r� Ucy /(A .Sc/{,,t��fd �8zs Shave .�✓ ��vevttE Q$Za 3 �ss 69cZ <br /> Owner MaJmg Address City Zip Phone <br /> SQ{'�� <br /> Appiicanl Mailing Address City Zip Phone <br /> Describe Proposed Work fl � �+V�7ti� �l V/ItT►_Dps1� ; f26NO�Q./ ke1�GCp4 <br /> Project Address(if known) 3 g Z� S�t0 C' i{-✓ .�e r tLr� � <br /> Attach four(4)copies of plans lor propoSeA work-Oraw to scale and note the following as applicable: � <br /> • Property Lines • Centerline ol stree� � <br /> • Outline and dimensions ol all existing and • Indicate Norih <br /> proposed structures on ihe lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measu�ements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be matle 24 hrs. in advance• phone 259•88�5. � <br /> 2. All work shall be performed in acrordance with this permit antl curreM City ol Everett Design and Construction <br /> StanCards and Specifications. <br /> 3. Call Location Underground Service 4B hrs. before you diy.TOLL FREE NUMBER �•800•424•55b5. � <br /> � (��`.'��� O <br /> � �t,r 1'-�''!'/s'�ij �L,:JT /�'EC��c'4�'E't� <br /> '-�`� � <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersi9ned owner/applicant hereby agrees to hold and save harm� <br /> less the City ol Everett Irom any and all claims tor damages, costs, <br /> expenses, or causes ol action that may arise bewuse ol installation <br /> and main nance ol ihe improvemenl olher right�of-way use herelo <br /> applied r and turther agrees to re ve same upon notice Irom ihe <br /> � Approved for Consiruction Date City an t replace pu ic property d ged thereby. <br /> FINAL INSPECTION Date ' � � �3 4 <br /> ApProved as ConsVucted Signature of Applicant Date <br /> everett PUBI.IC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Ceda�Slreet 180 DAVS OF DATE PFRMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 �E DILIGENTLY PURSUED TO GOMPLETIQN.THIS PERMIT MAV BE <br /> Phone:259•8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />