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Date�`�� Pu01¢WO�h9 PB�rtb�� _L3��� <br /> Biap.Deo�.• <br /> Appliwtion For <br /> PUBLIC WORKS PERMIT PublicWodsFee a� �� <br /> Totai Fee s <br /> LessApO�-FerPaiO S <br /> 0alanceDue s ��� <br /> i <br /> Print or Type Only — <br /> ar_�- �. Dlsrrv.. �1�15 �5� �-� ►•� S«��, faJRs �� �'18,5 -�j4�I <br /> �ner Mailing Address Ci:y Zip Phone <br /> jc-H. ..�� �-blo��— �S� S �.� 3 ��1�( ( c..J �..,� <br /> �x tm� GS R hov-e- �'��T L�c �� ( � 1��� ��// <br /> Applicant MailingAdo�ess City � ZiP P h o ne �,��^ <br /> u �i, . p f� 7 <br /> Describe Proposed Work I L� n u a`���1� Iv�� �nUY� � <br /> ��;..� __� , /� W <br /> Prolect Address(if knowr) � E�`x� �• s�'� `'�� 'r c �- P`- � � <br /> Altach tour(4)copies of plans for proposed work- Draw to scale and note the follow�ng as applicable: i <br /> • Properry Lines • CeNedine ol sireet � <br /> • Outline and dimensions ol all er.isting and • Indicate North <br /> proposed structures on ihe lot • Show any proposed grading chanc�es <br /> • Existing and proposed utilities • Show measurements � <br /> DO NnT WRITE BELO\Y THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance-phone 259•881 5. � <br /> 2. Ail work shall be perbrmed in accordance wilh lhis permit and current City ol Everet� Design and Construction <br /> Standards and Specilications. <br /> 3. Call Location Underground Service 48 hrs.betorc you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> � c����'ur�T C'�Tf/�i'�siiJ - .%y�'� i9 -- W iiy � <br /> ,�,.� .s;�����G' — s •—�o y"�� ��//o„ �id�`'��i1G <br /> <�� � <br /> S, ��'�� r'o•�e Ci7' si�`i'•�i9.�, VI <br /> 1�:� �� � ' � <br /> l. , �tiG�e� �`�Ir�.9�( �c r�y <br /> z_ p�P �-����� �z�,� � <br /> °��� r a <br /> JZ_� 1 ' <br /> ACKNOWLEDGEMEN OF CONDITIONS <br /> � The undersigned owner/applicant hereby agrees lo hold ani save harm• <br /> less lhe City of Everetl from any and all claims for dam�eges, costs, <br /> �� J . ezpenses, or causes of :.ction that may arise because c� installation <br /> j and maintenance of ihe improvement or other iight-ol-way use hereto <br /> .c' G applied lor nd lurther agrees lo remove same upon notice Irom the <br /> Approv � lor Construction Date Ciry to repla ublic properry damaged thereby. <br /> 5� 8� <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature o � Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everelt,VJA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259�8815 PROJECT OVER 90 DAYS DURATION. <br />