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� �� <br /> I <br /> c„oi�<wo��a oermn• � <br /> �.• Date�.�� amc oem., r/O/��/. �/_3 d <br /> qpplicati0n For � <br /> PUBLIC WORKS PERMIT P�ei¢wnrlafee g <br /> Tolal iee I <br /> Lesf�ool Fee Pa�� g <br /> Oaiana Oue S i <br /> ��y Print or Type Only <br /> � � �s� ���/ <br /> 38GG � Sin�ri! 5 �.�0/ <br /> CySCR,DE' L MailingAddress Cty ZP Phone <br /> �y y Owner <br /> � „ ,. Sa- VF7 <br /> "��r CitY Z�P Phone <br /> O x0 APP���a�� MailingAd ress <br /> � VJ H <br /> � �� Desc�ibe Proposed Work _ <br /> � �s W <br /> �,. � ` <br /> zH� — 3 0 � � � r <br /> 9 H project Address 1i1 knownl <br /> t' � <br /> ~y Atlach four(4)�opies ol plans for proposed work-Oraw lo scale and note I�e following as applicable: � <br /> y I-i • Property Lincs • Cenledine o�sireet <br /> � �y • Indicate Nor�h <br /> • Outline and dim^nsion=c�all ealsting and � ghow any proposed grad�ng changes <br /> r proposed strucWres on�he lot • Show measurements /� <br /> y • Eaisting and proposed utili�.ies W <br /> y �N �� DO NOT WRITE BELO�N THIS LINE O <br /> PERMITCONDITIONS � <br /> 1.All calls lor inspection shall be made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be pedormed in accortlance with ihis permit and current Ciry ol Everetl Design and Construction <br /> Standards and Specifications. � <br /> 3.Call Location Underground Service 4B hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. <br /> '` O <br /> .�.� <br /> '"' �' �w <br /> "� + . � �J' <br /> (,j �I <br /> � �L�/ O <br /> s! �Q e�/n�� a <br /> �_I 1 Q <br /> ACKNO�NLEDGEMENTOFCONDITIONS I <br /> � <br /> �' � The undersi ned owner/app�ican�hereby agrees to hold and save harm- , <br /> s 9 i <br /> lecs the Ci1y ol Everett from any and all claims lor damages, costs, <br /> ezpenses. o� ca�ses ol action ihat may arise because o� installation <br /> and mainlenance of lhe impravement or olher righ4ol-way use hereto <br /> I �'� applied �o� and lurther agrees lo remove same upo� nolice irom the <br /> qppro�ed lor Consiruction Dale City and to replace pu6lic p�operty damaged thereby. <br /> ' FINAL INSPECTION Date Date <br /> Signature of ApPlicant <br /> Approved asConstructetl WORK AUTHORIZEO BY 7HIS PERMIT MUST BE STARTED WITHIN <br /> Oeverett PUBLICWORKSDEPARTMENT 1B0 DNYS OF DA7E PER611T IS ISSUED AND THEREAFTEF �S TO <br /> 3200 Ce�ar Street BE DILIGENTLY PURSUED TO COMPLE710N. THIS PER.UUIT MAY BE <br /> Everett.WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Pnone:259�B810 PROJECT OVER 90 DAYS DURATION. <br />