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5 <br /> Y <br /> .�•a�e� Cup4r WOrhnPlamt• ��— /�2D �� <br /> Apolication for e�na o�o� • . �-��J— _ <br /> PUBLIC WORKS PERMIT °°�,o,rF�e`Ce s -_ <br /> LefsAp01 FeePxi� s -- <br /> BaianceD�•^ � 2�� <br /> Print or 7ype Only -- <br /> i ��►�� �is -ay*� s� /Sp//,�,,oh�,�. Q�aas G ��-9��,� <br /> Owner Mailmg Address � C�ry Zip Phone <br /> � ��icant Mailing Address City Z�p Phone <br /> Descrlbe Proposed Work ��/A! �� � ��� - Laf� _ <br /> ----_ ---- W <br /> ProiectAnd�esslilknownl ��.-:_C:�� — MF��D/A/J {�{/E, � <br /> Atlach four(4)copies of plans br prou��sed work� Draw to scale and nole the lollowing as anplicable: � <br /> • Property Lines � Centerline ol street � <br /> • Outline and dimensions o(all enisting and � Indicate No�th <br /> proposed structures on Ihe Io1 • Show any proposed grading changes <br /> • Ezisfing and proposed uhlities • Show measuremenis � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIODIS <br /> 1.All cells for inspection shall be m3de 24 :irs.in advance-phone 259•8810. � <br /> 2.All worY shall be peAormed in accordo'.ce with this permit and current City o1 Everetl Design and Construction <br /> Standards and Specifica�ions. <br /> 3.Call Location Underground Service�9 I:rs.before you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> �0 ACKNOWLEDG[MENT OF CONDI1lONS <br /> �� The undersigned owneUapplicant hereby agrees to hold and save harm� <br /> I less the Cily of Everett Irom any and all clsims lor damages. costs. <br /> n / expenses, o� causes ol aclion ihat may arise because of installation <br /> C �� " ��_`, � �/ � and maintenance ol ihe improvemen� or o�her righbof�way use hereto <br /> �� « appiir.d lor and lurther a9rees to remove same upen notice I�om the <br /> Approved ior Conslruction Date C�ty 2nd to replare pubhc pr�rty dama9ed ihereby. <br /> �/y� � <br /> �//.//c� /O' 6 '�/� (�(�( `�' <br /> FINAL INSFECTION � Dale { <br /> Approved as Censtrucled SignaWre of ApPlicant � Date / <br /> everett PIIBLIC WORKSDEPARTMENT WORK AUTHORIZED BY 7HIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarSveet 190 OAI'S OF DATE PERMIT IS ISSUE� AND THER[AFTER IS TO <br /> Everett.WA9B207 BE DILIGENTLY PURSUED TO COMPLETiO�'. THIS PERNiIT M�1' BE <br /> Phone:259-8810 CANCELI.ED BY THE GITY UPON ANY STOPFAGE OF WORK ON 7HIS <br /> PNOJECT OVER 90 DAYS DURATION. <br />