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� Pu�lic Warks Pa�mil s <br /> g5- �� 7 <br /> Date ���� Bltlg Depl.• -- <br /> Applicalion For <br /> WOR�(S PERMIT �'��b:icWo�ksFee $___ <br /> PU BLIC T"?'F�° <br /> ����Ao�,� FaA Pa�d � „?D D� <br /> Balance Oue <br /> Print or Type Only 760 �� <br /> L�f'� Ev�''� �T/�� P Phone <br /> ���� Mailing Address City <br /> Zi <br /> Owner <br /> �7 /��9�7� .3SS�—=�'-'�a' <br /> y� � �G, v f�X �i n�� f%7!_:� %� Phone = <br /> l�i9lL.AS t'�LSt7i(i �_�----' ciry zip o <br /> Mailin9 Address "' <br /> ppplicanl c <br /> �i' t-.� GEn/<� ;^ <br /> C�OrIJ_:::�G,,'T�L��S�t--� FAi"'y '�' � <br /> pescribe Proposed Work _— ,,,., „ <br /> �— --I -� <br /> — .____— A__-- - . n. —I <br /> —_----- '—'�— �r� �'m <br /> �, � o <br /> y�;��-23 � � <br /> ___ �.,_ m o <br /> La?- �d`2 �,�''eic:rl�i, . ;E'�7 rii��«� ��;��,.—._ A�E", l./, �: <br /> prolect Address(if known) � �� � m <br /> Attach fcur(4) ceF�es of plans tor proposed work• Draw lo scale and note S Cei�ie line of stre�i`a6 e: � _� <br /> m <br /> • Property Lines � Indicate North � <br /> • Oulline and dimensions of all existing and � ghow any proposed grading changes � �o z <br /> c <br /> proposed siruclures on the lot � Shcw measurements r = <br /> • Exi�•'^7 and proposed�6lities ., `-. <br /> � jv <br /> DO NO'f WRITE BELOW��HIS LINE � <br /> o :o <br /> � �y <br /> PERMIT CONDI'fIONS � <br /> –i r•� <br /> 1. All calls for inspection shall be mude 24 hrs. in adv2nce- phone ?59'i�8� � t� � <br /> 2. All work shall be performed in accordance with this permit and cui rent Ciry ot Everett Design and Construction � V <br /> Standards and ipecifications. <br /> 3. Call Location Underground Service�i8 hrs.betore you dig.TOLL F11EE NUMBEH 1-800•424-5555. n m <br /> O 3 v <br /> i r <br /> �m <br /> n <br /> � <br /> � � <br /> � <br /> n <br /> z <br /> O <br /> � <br /> V� <br /> a Z <br /> 0 <br /> � <br /> � <br /> �-: <br /> r-� <br /> ACKNOVJLEDGEMENT OF CONDITIONS <br /> The undersigne�+ �Wner/apPlicant h�reby agrees to hold and save harm- <br /> �-- less �'�e City of E�"� " from any and all claims for damages, wsts, <br /> -- exp�nsee. or causos ^� action that may arise ber,ause of installalion <br /> �� f 1-S�5 and mairtenance i the �mF�o�'ement or other right-of•way use hereto <br /> _ ' �1,.,.,/��i applied tor and fu�ther agrees !o remove same uPon notice from th.: <br /> '�—='� ate Cily and to replac^ public prop��rry damaged therebY. <br /> Approved for Const uction d� <br /> (],,,n„A , � ' o <br /> � /� C�`,�-���' !�t� _ _ - <br /> Date �2"`— Date <br /> FI!JAt ISPEJTION SignaWre ol Applicant <br /> �•FFroved as Conslrucicd WOFK AUTHORIZED 6Y THIS PERMIT MUST BE STARTED WITHIN <br /> PUBLIC WORi:S DEPARTMENT 180 DAYS OF DATE PERk11T IS ISSUED AND THEREAFTER IS TO <br /> everett BE DILIGeNTI.Y PURSUED TO COMPLETION.Thi1S PERMIT PAAY BE <br /> � 3200 Cedar Stree! CANCELLED 3Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Everett,WA 98201 pROJECT OVER 90 DAYS DURATION. <br /> Phone: 259-887 5 <br />