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9 tx-3 to <br />`4 0 <br />H <br />` <br />* H <br />Cr1 Lo <br />O E <br />H t7 <br />O H <br />Hag <br />yH 1 <br />E' <br />~H <br />g� H <br />C]Cw <br />z0 <br />HO(Arn <br />rs <br />1 <br />.r,_ JQ <br />c <br />Datel:? <br />r-r Application For <br />PULIC WORKS <br />Print or Type Onl Bass <br />oimm <br />Applicant <br />Describe Proposed Work <br />Project Address (if known) _ <br />Public Works Permit. <br />Bldg Dept-. _ <br />PERMIT P°b°°Works Fee 0 — <br />c Pee <br />Leas APPt- Fee Paid $ <br />Balance Due $ <br />Mailing Address City <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the list • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />Phone <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8810. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800-424.5555. <br />Cc�n �o> tell e 9 - z7 - 9 C' / <br />rf 62? cZ //Rrf (%n CL P/✓D S/GZ L ! / C <br />UJ <br />CIO <br />M <br />z <br />O <br />� r�w■ <br />C/ <br />O <br />am <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />-- -- less the City of Everett from any and all claims for damages. costs, <br />expenses, causes of action that may arise because of installation <br />. , and maintenance of the improvement or other right-ol-way use hereto <br />sr� applied for and further agrees to remove same upon notice from the <br />edlor�uc�� fDate I City and to replace public property damaged thereby. <br />c �t <br />ICALYNSPECI'1 ry � Date <br />pproved as Cons rutted r Signat(irff Applicant D to <br />WORK THORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />Everett, WA 98201 CANCELLED BY THE. CITY UPON ANY STOPPAGE OF WORK ON THIS <br />everett <br />Phone: 259.8810 PROJECT OVER 90 DAYS DURATION. <br />I <br />