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Date�y�l"j \���s <br />Applicalion For <br />` PU�LIC ��/�RKS P�RMIT <br />Print or Type Only <br />Applicant <br />Describe Proposed Worl� , � <br />���`� l ♦ <br />�� !�� \ r.�.,. <br />-�"� �'l`a'l= � , <br />j� <br />Prcjec� Address (if kr�own) ` <br />Mailing <br />Mailing Address <br />Attach four (4) copies of ?lans for proposed work - Draw to s <br />• Prope;ry Lines <br />b� Outlina and dimensions of a:� existing and <br />proposPd structures on the lot <br />• Existing and proposed utilities <br />Z.S <br />�� <br />Zip <br />i <br />Pu01¢ Works Pernp • <br />9s oe� ' <br />Bltlg. DBp1. f <br />ru0lic Works Fee <br />Total Fee $ <br />Less Aool. Fee PeiO $ <br />Balanca0ue $_� '�� <br />T� a� co�cEcrEn <br />�✓�nv unc�ry ,p,�,;� <br />� pE2miT. <br />Phone <br />> (.owe� �VD!` �sN lir e `�if� \ . <br />antl note the tollowing as applicabb:: <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERM!T COtJD!TIONS <br />7. All calls tor inspection shall be made 24 hrs. in advance - phone 259-8810. <br />2. All work shall be peAormed in accordanca viith this permit and current City of Everett Design and Construction <br />°�;andards and Specifications. <br />��-all Location Underground Ser�ice 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424-5555. <br />� <br />S <br />Th'rOh4h/ af�ti ak, l noc✓ _/ ' �, • / <br />� 7��" (C,Ufih� OeS/9h �rycSe� <br />P�,-,�a ti � � f P� �� � P�,- �; �y s�4 ., ,� ,-ds ��. �� <br />Cohf.oC _ G�Pn.f�{ B4c �C� / <br />/ y � Qi�'�— �C'rr.��nen 7 C'tJh.-icc�i7 /� <br />I�'� R G�'C <br />(�%� If.rv ffi �ia-h-L �/y/9S <br />ApprovedforC struction , � Date <br />�`/ �— <br />� <br />FINAL IIJSP�C`f Date <br />Approved as Constructed <br />�AA���� PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259-8810 <br />ACKiJOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />�w <br />_ / <br />� <br />� <br />The undersiyned ouvner/applicant hereby agrees to hold and save harm- <br />less ihe City of Everetl irom any and all claims for damages, costs, <br />expenses, or cau�es of action ihat may arise because of installation <br />and maiMentmce ot ihe improvement or other righbohway use iiereto <br />a, plied for ard furiher agraes to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Z <br />Signature of Applicant Date <br />WORK AUTHORIZ THIS PERMIT MUST BE S�lARTED �VITHIN <br />180 DAYS OF DAT ERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLE� BY THE CITY UPON ANY STOPPAGE OF WORK ON TIiIS <br />PROJECT OVER 90 DAYS DURATION. <br />