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Date�'_/>�'fi yc5c'�'/b/ <br /> r��oi,,:wo,w,Pc,mn. �(� 2 <br /> APPIiCatmn For n�nq ocni • �Q J3_ _1--- <br /> PUBLIC WORKS PERMIT °°°:o„�:�°°° : — <br /> leee Rppl.fec Pn�a S <br /> Balance�on 5 =�� <br /> Print or Type Only <br /> ��, (,�,l0 3 / 7/i Lu S.fv�iLa�P /�cl EvniP Q�_�y .�oL <br /> Owne� Mailing Address Ci1y Zip Phone <br /> �c.�l� � .7 / n.an/n�'nv1��/�—�(28 �H ,(`�-.f i�� � iv QJ'zaY 3y�-02{�� <br /> qpplicant Mailing Address Cily Zip Phone <br /> Descrlbe ProposeC Work C(}y(j���l� J- �'�l���n�0'Q�-Q, <br /> tl <br /> � <br /> (� / _ / � W . <br /> Prolect AdOress I�f known) � �� �—�/ • J i�L�/' L f� � I, <br /> Attach lour(4�copies of plans lor proposed work� Draw to scale and note the following as applicable: � 'I <br /> • Property lines • Centerline ol street � � <br /> • Outline and dimensions of all e*isting and • Indir.ate North <br /> proposed sirucW res on Ihe lof • Show any proposed grad��n changes <br /> • Existing and proposed utilities • Show measwements � <br /> DO NOT WRITE BELOW TIIIS LINE � <br /> PERMIT CONDITIONS <br /> 1.AII Alls lOr inspeCtion Shell be mede 24 hr5.in advanCe-phone 258•8810. � <br /> 2.All work shell be pedormed in accordance with this permit and wvent City ol Everett Design and ConsVuction <br /> Stendarus and Specilications <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FNEE NUMBER 1-BOO-424•5555. � � <br /> � ( <br /> � <br /> � <br /> O <br /> a <br /> �CKNOWLEDGEMENi OF CONDITIONS <br /> The undersigned owneriappliwnt hereby agrees to hold and save harm- <br /> — - less Ihe Cdy of Everett trom any and all claims tor damages, costs, <br /> expenses. or czuses ot action Ihat may arise 6ecause of installation <br /> � _ ��� 1�L /'- f/ `U/�B and maintenance of ihe improvement or other right-obway use hereto <br /> ��»'J'� �` applied lor and lurther ag�ees lo remove same upon notice irom ihe <br /> Appwved Constrtictlon Date City and to replace puUlic propvty damaged thereby. <br /> l� j' � � � ' <br /> � � � <br /> FINA INSPECTI � J Date � /� �- � `� ` �S � <br /> Approved as Consiru�ted Signature ot AppGcant Date <br /> WORK AUTIIORIZED BY THIS PERMIT MUST B[ STARTED WITHIN <br /> evereu PUBLIO WORKS DEPARTMENT ig0 OAVS OF DA7F PERMIT IS ISSUED AND THcREAF7ER IS TO <br /> � 3200CedarSireet BE DILIGENTLY PURSUED TO COMPLETION. iHIS PER�diT MAY BE <br /> Everett,WA 9820i CANC[LLED BV TN[GTY UPON ANV STOPPAGE OP WORK ON iHIS <br /> Phone:259�BB10 pROJECT OVER 90 DAVS DURATION. <br />