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Date� f <br />Application For <br />PI�BLIC WORKS PERMIT <br />Print or Type Only <br />P�o6c Wor4� P rmp • O�y �] <br />Bltlp. DaoL • J V K <br />PueLc WorMs Fee ' <br />Tal�l Fss f <br />l��+ApOf Fm Paid i <br />e.�.��. o�. <br />/�UUICd.I <br />Descdbe PrOposed Work Yi.i(9c�� S(�,Q � � f,v <br />� ��_ C /�c�0 �,.� <br />Pro�eCt Address (il known) <br />Attach lour (4) copies of plans for proposetl work • Uraw to scale <br />• Property Lines <br />• Outline end dimensions of ail existing and <br />proposed slructuras on th� lut <br />• Ezisting and proposed utllitles <br />PERMIT CONDITIONS <br />Zip <br />note the following as app!icable: <br />• Centerline ol sireet <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />1. All cells lor inspe�tion shall be made 24 hrs. in ativance • phone 259-881 5. <br />2. All work shell be performed in accordance with this permit and currenl City ol Everett Design and Construction <br />Standards anA Specilications. <br />3. Call Location Underground Service 4B hrs. be�ore 1ou dig. TOLL FREE NUMB�R 1-$00•424•5555. <br />� P w o�-�s <br />� ��i« <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Construcletl <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett. WA 98201 <br />Phone:259-8815 <br />1 p—r 1..n � -7 <br />1�-e � �.t ( �'C r 1� <br />CCJ' —v <br />s� <br />ACKNOW�EDGEMENT OF CONOITIONS <br />W <br />� <br />�w <br />_/ <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersiyned owner/applicant here6y agrees to hold and save harm- <br />less the City ot Everelt Irom any and all claims lor damages, cosis, <br />expenses, or causes of acticn Ihat may arise because ol mstallation <br />and maintenance ol the improvement or other righPol-way use hereto <br />applied lor and lurther agrees lo remove same upon notice Irom the <br />City and to replace puFlic property damaged Ihereby. <br />Signature ol Applicant Date <br />WORK AUTHORIZED B'/ THIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DATE PERMI( IS ISSUED AND THER[AFTER IS TO <br />BE DILIGEN7LY PUFSUE7'O GOMPLETION. "iHIS PERMIT MAY BE <br />CANCELLF.D BV THE Clil VPON ANY STOPPAGE OF IVORK ON THIS <br />PROJECT OV[R pp DAYf DI IRATIOP;. <br />C <br />r <br />C7 <br />H !- <br />y <br />H �- <br />� C <br />C G <br />[J t <br />C� <br />�: <br />� �. <br />�. <br />H r <br />�C <br />Ot <br />�� <br />�; <br />�i'Z'r, <br />y ; <br />