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(-'` I <br />�X <br />Date___ � <br />Application For <br />�UBLIC W�RKS PERMIT <br />Print or Type Only <br />.S� /�� �? / �.-.- <br />Applicant <br />Mailiny Address <br />ng Address <br />.. Pe1�M1c lVo.lz Prrnnt • I . <br />&n9 Depi � �1I _��� <br />« <br />Vebi�c 1Yorxs Fee <br />r�:,� F�� s _ <br />LessAnoi F?rPani 5 <br />pamnre �uc �u _ <br />City 7ip Phone <br />Gty Zip Phone <br />Describe Proposed Work � � ���� � ��J�� `�'� � � � 1c �� _ <br />Prniect Address (il kncwnl <br />Attzch lour 1�) copies ol plans lor proposed work - Draw lo scale antl note the following as apPlicable� <br />• ProPerlY Line� <br />• Outline and dimensions of all axisting antl <br />proposed structures on the lol <br />• Exis�ing and proposed utilitie5 <br />• Centerline of street <br />• Indicetr, hlorlh <br />• Show any propo5ed 9radinq changes <br />� Show measurements <br />PERMIT CONDIlIUNS <br />1. All calls h�� !nsoection shall be made 24 hrs. in advance - phone 259•Sa10. <br />2. All work snal�. be perlormed in accordance with inis psrmil and wrrent Ci�y oi Everett Design and Cons�ruction <br />Standards and Specificatiors. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL �REE NUMBER 1•800•424•5555. <br />F.pproveA for Construction <br />FINAL INSPECTION <br />App:oved as Construcled <br />everetl PUBUC WORKS DEPPRTMENT <br />� 3200 Cedar Str��et <br />Everett WA 99201 <br />Phone:259�8810 <br />� „ �- <br />���� ���� � � f� ��� . <br />�!�� �1°a-�'"-' <br />S-iB-8� <br />ACKNOWLEDGEPdEPiT OF CONDITIONS <br />� <br />O <br />The undersigned owner/applicant horeUy agrees to heid and save harm� <br />iess thc Gty of Everett Irom any antl all claims lor damac�es, costs. <br />eaUenses, or causes of action thal may arise bccause of installation <br />znd mainlenance o! Ihe improvement or other nghi-of-way use hereto <br />3pplied lor and lurthr�r a�rces lo remove same upon notice Irom the <br />Date City anA to reploce nu6lic pioPerty d�maged Ihereby. <br />Date _ <br />Siqn��we o� Applicnnt Gale <br />WORK AUTIIORIZED BY THIS P[RMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTE!7 IS TO <br />BE DILIGENTLY PURSUED i0 COIdPLET10N. THIS PERMIT MAY 9E <br />GANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK JN THIS <br />PROJECT OVER �0 DAYS DURATION. <br />