10901 I-5 2016-01-01 MF Import - Laserfiche WebLink

Date��"�� F�o��wo,ksP��m,� _.� � Applica�ion For o�ae oeni + PUBL�I� WORKS PERI�JIIY P��I¢WoiksFee To�al Fee S LessAppi FecPaid S Baiance Oue S Print or Type Only �2�F i��.n� p�y� � Mailing Address Ciry Zip Pnone Applicant Mailing Address Gty Zip Phone U.�cribe Proposed WorA �1 J -U f ��' 1 ��`IoLI—J � �� \� � /-A /�j' � Project Address(i� hnown) r�� Ll r� � l Atlach four(4)copies o� plans lor proposed work- Draw lo sr,ale and no the lollowing as applicable: � • Property Lines • Centerline of sireet /A • Outline and dimensions ol a'I existing and • Indicate North �/� proposed siructures on ihe lot • Show an� proposetl gradinc� r.hanges • Existing and proposed u�ilities • Show measurements A/� � . W DO M1�JT WRITE BELOW THIS LINE O ?ERMIT CONDITIONS 1.All cails for in;pection shall be made 24 hrs.in advence-phone 259•8810. ^ 2.All work shall be pedormed in accordance with ihi�permil and current Ciry of Ev2ret!Desigr,anA Construction ♦ Standards and Specifications. 3.Czll Location Underground Service 48 hrs.hetore you dig.TULL FREE NUMBER 1�00-424•5�55. � � f'l�`��T t��U I Y�� " �-� G�� N O � ACKNOWLEDGEMENT OF CONDITIONS The undersi9ned owner/applicant h2reLy agrees to hold and save harm� — — less the City of Everett Irom any and all r.laims for demages, costs. expenses, or causes ol action that may arise because ol installation and maintenance of the improvement or Mhe� n�hbol-way use hereto __ apt�lieC for and lurther agrees to remove same upon notice Irom the Approved for Construction Da!e Ciry and to replace public property damaged �hereby. FINA'_ INSPECTION Dale �----- Appr�ved as Cuns�ructed Signature ol Applicant Date WORK AUTHORIZED C3Y TNIS PEFMIT �dUST BE �TAFTED WITHIN ev.�relt PUBUGWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND 1H[REAFTER IS TO � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLET'ON. THIS PERMIT MAY BE Everett WA 98201 CANCELLED BY 7HE CITY UPON ANY STOPPAGE OF WORK O� THIS Phone:255-A870 PROJECT OVER 90 UAYS DURATION.