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r ! <br /> (�� � 'f,� � � ,{�/ ��j '.� Pu�lic Wo�hs Pcrmi� ��� .. <br />' Date �/ �n{ LS lJ L� U L� � I�Cr Jr <br /> U U emn.oeo�._ <br />�i � Applicati�.;n For _ <br /> PUBLIC WORKS PERI1A��t�'' �719�' PublicWorksFee $ .� . � ,� <br /> Tolal Fee <br /> ..................................................................�.. Less APPI.Feo Paid $. — <br /> CITY OF E�/ERETT Balance Due s `�-v•� � <br /> Print or Type Only P:'�:i� 1^!orks De,r,,, ,66/3a <br /> �o �n l�esa � `� �tz $ 43��I �UL "� � Cz� � l `i �C�a3 � � �1 ._� k�t7 <br /> Owner <br /> Mailing Address Ciry Zip Phone <br /> 1� ;–� r�1 �ui' 1 �� 4 �1 �l �aa3 �s�-�� �� ) <br /> ll'�'N l�7eV'q ���7a-FS �� � Zi rnone <br /> APp���a��T Mailing Address C��Y P <br /> Describe Proposed Work <br /> I► ln `–FQ�nA Q� - <br /> - W <br /> � ► � � ay ��. s =- !— <br /> Prolect Address(if known) yO <br /> —�� �� <br /> Altach four(4�cop:es ef plans for pr:�posed work- Draw to scale and note the followin5 as applicable: � <br /> • Properry Lines • Centerline of street <br /> • puNine and dimen;�ons o'ali a.!^_ting and • Indicate North <br /> proposed str�;.:tures on ihe lol • Show any proposed grading changes <br /> i Existing and proposed utilities � Show measurem?nts M <br /> W <br /> ��'�—_� D�1 NOT WRITE BELOW TH10 LINE O <br /> PERMIT CONUiTIONS � <br /> 1. All calls for inspection shaii be made 24 hrs. in advance- phu�ie 259-881 5. � � <br /> 2. All work shall be performed in accordance with this permit ��d current City�f Everett Design and Construclion , <br /> Staudards and Speci(icationa � ' <br /> 3. Call Location Underground Service 48 iirs. betore you di�.TOLL FREE NUMBER 1-800•424•5555. <br /> O ' <br /> � ' <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> Thc undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everett tiom any and all claime for damages, costs, <br /> i2!!� � exPenses, or causes of action that maY arise because of installation <br /> �� /�f.3 and maintenance of the irtiprovement or olher righ4ot-way use hereto <br /> applied for and turther agrees to remove sarr�e upon notice from the <br /> Approved for Construclion Date City and to replace public property damayed thereby. <br /> �_,..���'',� 3�3-�y _�� , _ � �, <br /> FINAL INSPECTION Uate � Da� <br /> Approved as Constructed Signalure of ApplicanY \ <br /> WORK AUTHORI'_ED BY THIS PERMII�WIST BE STARTED WITHIN <br /> everett PUBLIC WOfif<S 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 8H2O1 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 PRJJECT OVER 90 DAYS DURATION. <br /> � <br />