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i <br /> I <br /> Date��D I P��hi��wo,wsP��m�i �JC3''')79j/�Z�s� � I <br /> Application For ��a;� oeni.• ----=����_[.C�[{�[��_ I I <br /> V,�bhr,WorFSFeo I I <br /> PUBL.IC WORKS P�RiVIIT ,o,„,F�� 5_ � i <br /> LeSSApPI FeePaitl S I <br /> Calancc Due $ �� <br /> Print or Type Only - - <br /> ��etr�'�_�'�l;�� 1�8 �(1 /�7� ���:f�lP G18/� � ���—�. <br /> Owner Mailing Atldress Gily Zip Phone I I <br /> �� H <br /> Apphcant Mailing Add�=ss City Zip Phone � <br /> Describe Propasetl Work ���� - (��r � ( � �ftfr�-/�,/yC �. <br /> � <br /> � <br /> G� '_ L/���� S� SlC.' . � '� <br /> Proiect Address(if known� � <br /> Attach four(4) copies of P�ans for proposed work� Draw to scale and note the following as apPlicable: � �'� <br /> • Properry Lines • Cen�erline ot sireet /� I <br /> a Outline ar�d dimensions of all e>.isiio9 and • Indicate North V� <br /> proposed slructures on ihe lol • Show any proposed grading changes <br /> • Existing and pioposed utilities • Show measurements � � <br /> i <br /> DO NOT WRITE BELOW THIS LWE o I <br /> PEHMIT COMDITIONS <br /> 1.All calls for insp�ction shall be made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be peAormed in accordance with this permit and current Ciry nf Everett Desi�n and Construction � �i <br /> Standards and Specifications. I <br /> 3.Call Location Unde•ground Service 48 hrs.betore you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> � �I <br /> i <br /> �p I <br /> i/ <br /> � I <br /> � <br /> � �,� ACKNCVJLEDGEMENT OF CONDITIONS <br /> � � The undersigned owne�/applicant hereby a9rees to hold and save hnrm- <br /> less the City ol Everett from any and all claims for damac�es, costs. <br /> ,[�/. � �1 p expenses. or causes of action that may arise because ol installation ' <br /> <��1;� Q(�Y�'.� O /./ G� and maintenance of the imProvemenl or o�her nghf-of-waY use hereto i <br /> ✓/ T ri applied lor and furiher agrees to remove same upon nolice from the <br /> � / <br /> Approved for Conslr �ion Dale Gity and Io replace public property damaged thereby. <br /> �ll�� g _ 6- ��, <br /> FINAL WSPECTION Date G <br /> Approved as Construcled S 9n ture ol Applicant ate <br /> evrretl PUBLIC WORKS DEPARTMENT K AUTHORIZED B HIS PERMIT MUST BE STARTED 'NI?HIN � <br /> � 3200CedarSt�eet 0 DAYS OF DATE RMIT IS ISSUED AND THEREAFTER �S TO <br /> Everett WA 982Gt BE DILIGEN'LY PUR UED TO COMPLETIOtJ. THIS PERMIT MAY BE <br /> Phone:259-8810 CANCELLL. "i THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER f30 DAYS DURATION. <br />