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Date/� Pu�LCWOMSPermi�e c7J ' ��;�
<br /> Bleg.Depl.•
<br /> Appl�.cation For
<br /> PUBLIC WORKS P�RMIT PUGTa�FeeFee g
<br /> Less Appl Fea Pa�id �
<br /> Balance Due �
<br /> !L� ��r
<br /> Print or Type Only
<br /> .�53-y6 7y
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<br /> �/J,� T�sS.._, JoN� � - .7D//f .�J .71/6� L!/6.L�ETy /.JA. ��ae.3 Z
<br /> Owner Mailing Address C��Y Z�P CDLGN6CE Phone o
<br /> —9 /IIIf�%r75�'l- S//O/ �
<br /> I LL/J� �/ � Ai n
<br /> ,r .1.s O/1� a?3�� %NF l!J• /-rE=,PEiT .,,03 353- �•>� ;"
<br /> Applicant Mailing Address City � Zip Phone
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<br /> Describe Proposed Work ��' ��/—�---"--�'f� �'����J � �mi�'� N =
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<br /> �Ql11ef•�j7J1� :-�i 5//i 3 � �LLu• � / � _-�
<br /> Project Address(if known) m
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<br /> Attach four(4j copies of olans for proposed work- Draw to scale and note the lollowing as app'icable: � c Z
<br /> • Pioperty Lines • Cent=rline of street � r =
<br /> • Outline and dimensions of all existing and • Indicate North `� `�
<br /> � N
<br /> proposed structures on the lot • Show any proposed grading ch�nges < .n
<br /> • Existing and proposed ulililies • Show measurements /M o D
<br /> DO NOT WRITc BELOW THIS LINE � '� m
<br /> m �
<br /> PEHMIT CONDITIONS O N
<br /> 1. All calls for inspection shall be made 24 hrs. �n advance- nhone 259•f381 5.
<br /> 2. HII work snall be performed in acco;dance with this permit and current Ciry o( Everetl Design and Construction � 3 N
<br /> Standards and Specifications. m
<br /> 3. Call �oc.tion Underground Servlce 48 hrs. b�fore you dig.TOLL FREE NUMBER 1-800-424•5555. � �r
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<br /> ACK�IOWLEDGEMENT OF CONDITIONS
<br /> The undersigned owner/apP�i�aM hereby agrees to hold and save ham�-
<br /> --- —' less lhe Giry of E��erett Irom any and all claims for damages, costs.
<br /> � «� �• � expenses, or causes ol action �ha� may arise because of installation
<br /> � 7 i
<br /> ��� � y /�'� and maintenance of the improvemenl or olher righl�of�way use hereto
<br /> `�--' �G—L,���`��J� " ��," ;}'' applied lor and �urther agrees to remove samc upon notice from the
<br /> Approv%:d for Gonstruction � 1e City and to replace pubtic property damaged thereby,
<br /> .� /
<br /> /- Z8 -86 �y� ,
<br /> Wi AL IMSPECTIO Date //.�J�-' ' .l���l'i :_/ i L-i=����„�"� % �.J!.'`.}��7.�
<br /> Approvnd as Constructed Signat of Appb,cant � Date
<br /> WORICAI'�fHCRIZED �'f THiS PERMIT MUST BE STARTED WITH!N
<br /> everett PUBLIC WORKS DEPAFTMENT 180 DAY3 OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO
<br /> � 3200 Cedar Slreet BE DILIC�ENTL'�' PURSUED TO COMPLETION. THIS PERMIT MAY BE
<br /> Everett, WA 98201 CANCC-LLED BY THE CITY UPON ANY STOPPAGE OF WORK UN THIS
<br /> Phone: 259�8815 PROJECT OVER 90 DAYS DURATION.
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