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Cate���� f� ' � — z`i `5 <br />Applicatian For <br />PUBLIC WORKS PERMIT <br />Print or Type Onty <br />SD �, � <br />AppliGent <br />AAdress <br />Mailinc� Addres5 <br />z�n <br />Lip <br />1`�iplir. WOrA51��•�Til � <br />ov� Doni • � �_ <br />Pw�im wo,ka rae <br />imni Fne S __ <br />L«ss nro� iec va�a S��_ <br />�,Ian.,,Du� S SO <br />Describe Proposed Work �l'[�! St�+6,_ ��F Y�.0 iJ�L f�Ji' ���(CP � i.o�5 .Zq—,�� <br />T <br />Proleci Address lif known� <br />Attach four (4) copies ol plans for pmposed work • Draw to scale antl note ihe lollowing as applicable: <br />• Property Lines • Centerfne ot slreet <br />• Outline and dimensions of all existing antl • Indicale Nor!h <br />proposed structures on the lot • Show any proposed giading c�anges <br />• Exisling ond proposed utilities • Show measurements <br />pprovetl ns <br />everett <br />e <br />Phone <br />PERMIT CONDITIONS <br />1. All cells for fnspection shall be made 24 hrs. in advance • phone 259•8610. <br />2. All w�rk shall be pertormed in accordance with this permit and current City of Everett Design and Construction <br />Standerds end Specificetions. <br />3. Call Locatlon Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424•5555. <br />�i Q�gaB�ca..,7` ,� �e� ��o/� .z5 .c�-�.a�sa� � �'nm:th� <br />�t/�i C� �a-�+ ad 4.e/� � 3U3 4�wa� ,�,r.��� .�0�.�.u?.�� <br />�c.r� Geuili'oY✓ .S�t.� i� <br />-� �J` �cCd� /,o �LU �Ol�co-�e/ Q.� �(1F*'r�07/!r(GnLGe- �.!!2'I4��' <br />Im, �Ja1� �ze�iu 'k`cn� �'v2i��,a, �.1� �e. ,c�c�ti���_ <br />'�J.... i ���%Li(^ � � r... // ��l ' � <br />PUBLIC WORKS DEPARTMENT <br />3200 Gedar Street <br />Everett, WA gB201 <br />Phone:259�8810 <br />v � <br />Date <br />��—% � -iQ <br />Date <br />ACKNOWLEDGEIvi��.l Of CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />The undersigned owner/applican�. here��y agrees to hold and save haim• <br />less the City ol Everetl from any antl all claims for damages. costs, <br />expen,es, or causes ol . ction �hal may arise because of installalion <br />and maintenance ol the improve�nent or o�her right•ol-way use hereto <br />applicd lor and lurther a�rees to remov� same upon notice hom �he <br />Clly nnd lo replace pub�� . i iperty damagetl Ihe�eby. <br />• N �.� ��/i� `' ` <br />Sig a ure ol Appficant �ate <br />WORK AUTHORIZEO BY THIS PERMIT MUST BE STARTED WITHIN <br />160 DAVS Of DATE PERId1T IS ISSUED AND �iHEREAi°TER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPOM ANV STOPPAGE OF WORK ON THIS <br />PNOJECT OVER 90 DAYS DURATIOti. <br />