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oate 5 �/� UO r�oecwo��sr��mi. -- <br /> eme oco� • — <br /> Application For <br /> PUBLIC WORKS PERNlIT °°„'""'°'""`° s — <br /> iotnl Fec <br /> less Rppl.Pee PaN s <br /> oaia�c«o�� S <br /> Print or Type Only <br /> I �i(o�`� S:/vut%��FAN(e E���Yf 95rr.��3 a�s -9�O3 <br /> CORc OR • ��A�I`� Y` — <br /> Own r Mailing Address City Zip Phone <br /> ��oR k <br /> �{S4-3oZ I <br /> SIEN•-z ►45 AYro�C� — <br /> Applicant Mailin�Address City Zlp Phone <br /> Tli-c.. 1�Ac.�C AILT ��� m l.ot i s �, y�n11 ey o.nd 41�.a. n � � <br /> Describe Proposed Work � � � <br /> C,io�a, H��l1�C SA�d w� c. uld ^fak• t+:s Fen�c_ dow� o,.r� � 8ack 0_ u.+,e �aFcs�9 <br /> -�I.�..�R�put�y (;v.a_ ._A Ncw a h�n� ���� th i T -r s s <br /> a�� l,ICe., �� �� i� fi� wl�c Su a hn� d nn--� AR ?�C he� rw o S � <br /> �e�4 S�����T� �.+9�oZ� C-�� ��G�k�f'o ���I i f •i/� AISe� <br /> Project Address(if known� P <br /> � <br /> Attach four 14)copies ol plans for proposed work� Draw to scale anA nole the lollo ng as applicable: � <br /> • Property lines • Cente ine ol street <br /> • Outline and dime�sions of all existing antl • Indicate North <br /> proposed structures on ihe Iot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremeMs M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> 1 <br /> PERMIT CONDITIONS � <br /> t.All calls lor Inspection shall be made 24 hrs.in advance•phone 259•8810. <br /> 2.All work shell be pedormed in accordance with this permit and curreM Ciry ot Everett Design and Construction <br /> Standerds antl Specitications. � <br /> 3.Call Locatio�Underground rvice 46 hrs.before you dig.TOLI FREE NUMBER 1•500-424•5555. <br /> / � O <br /> i"1 /� �� � �f��� ' ���� � <br /> � � /� � ,�'� . �- �JN <br /> ������ � ���������A��� H <br /> JG��„C��cSs���,�i..L s� i � <br /> ��lSv� �'� �,v�r f FL N <br /> ,/ �'C�SS �° .��;�/� O <br /> � a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersi�ned owner/applicant hereby agrees to hold and save harm- <br /> ' less the CAy ol Everetl Irom any and all claims br damages. cos�s, <br /> expenses. or causes o� action that may arise because of installation <br /> and maintenance ol the Improvemenl or other righ�-o4way use hereto <br /> applied lor nnd further agrees to remove same upon notice trom the <br /> Approved lor Construction ��a�� City and to replace Puhlic prcperry damaged ihereby. <br /> FINA1. INSPECTION Date Dale <br /> Approved as Conslructed Signature of Applicant <br /> WORK AUTHORIZLD BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 1B0 DAYS OF DATE- PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CetlarStreet DE DILIG[NiLV PURSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Everetl.WA 98201 CANG[LLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phonc:259�8810 PROJECT OVER 90 DAYS DURATION. <br />