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Date�o 7 <br />Applicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />City <br />Pu�l¢ Wads Pormit � _ `� � r /�� <br />niae oani., � ' �. <br />Publm Works Fao <br />Talal Fvo S <br />L059 AOP� �CB Peitl S <br />Balenco �ua S �� <br />� �SAt'Yl F <br />Appliwnt Meiling ACdress Gity Zip Phone <br />Describe Proposed Work � ��a A� ��'\C <br />Prolect Address (il known) 5��9 ` SOUif/.CJ �G�E ___ <br />Attach four (4) copies of plans for proposed work - Draw to sca�e and note the followin;� as applicable: <br />• Property Lines <br />• Outline and dimensions a' all existing and <br />proposed structures on the lol <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />• Centerline ol slreet <br />• Indicate Norlh <br />• Shuw a�y proposed grading changes <br />• Show measummenls <br />'{� <br />1. AI� calls tor inspection shall be made 24 hrs in advance - phone 259•8815. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications <br />3. Call Location Underground Service 48 hrs. before you di�. TOLL FREE NUMBER 1-800•424•5555. <br />3� Z.�r.y�l �,�,��«qy c�,� � cvT �-� �; ; � sT�,��n <br />/�`307 9.�/o C�'c'7,.-�tJ "3..�.? • <br />� <br />ci .t�JCze��— .:s � �% <br />AnProved tor Constru o� Date <br />� !u-/ —�i� <br />I� INSPECTION Date <br />Aooroved as Construcled <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl. WA 98201 <br />Phone: 259•8815 <br />ACY,NOWL�DGEMENT OF CONDITIONS <br />� <br />� <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />� ne undersi9ned owner/applicant hereby agrees to hold and save harm• <br />less ihe Cily oi Everet� from any and all claims for damages, costs, <br />expenses, or causes oi action that may erise because oF installetion <br />and maintenance of the imprevement or other righFof-way use hereto <br />applied for dnd lurther agrees to remove same upon notice Irom the <br />City and to replace public property Aamagad ihereby. <br />I � ���z� � s/� � <br />Signature of Applicant Date <br />WORK AUTHORIZCD BY THIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DA�E PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE D:LIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON ANY STOPPFGF OF WORK ON THI5 <br />PROJECT OVER 90 DAYS DURATION. <br />