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:, I <br />�': // ,�`� �"`"� � <br /> Date�/ �� + � Public WmhS Pe�mil e <br /> ' Application For BIdB-Ocpi.s r�/�cf'�A I <br /> PUBLIC WORKS PERMIT PublicWorkSFee S � <br /> To�al Fee I <br /> � Less AOP�.Fee Paid $ <br /> Print or Type Only Balance0ue $ i I <br />; ; I <br /> I <br /> �- I.. � a n�r Z, 7C� z� '-r t`� � ]C r �r� -1-� I � <br /> ' Owner Mai4mg Address Ciry Lp Phone � <br /> I <br /> i� ��i ,� r�.��-�- Sas� �N�/�����„ ti, CQ ,�/Q 9��a3 3�ryisn <br /> . ��plpan� Mailing�dress City Zip Phone <br /> Describe Propused Work �-�� ���/l-1�� f� , <br /> W � <br /> , <br /> . Prolect Address(f known) 3 7Q �- Z-1 y�`�� � ' <br /> � Attach four(4)copies of plans for proposed work• Draw to scale and note the followinq as applica6le: � � <br /> � • Property Lines • Centerline of street � �� �;� <br /> • Outline and dimensions of all existing and • Indicate North � . <br /> ' proposed structures on the lot • Show any proposed grading changes � �. <br /> �. • Existing and proposed ulilities � Show measurements � i - <br /> � DO NOT JJRiTE BELOW THIS LINE O �� <br /> i <br /> ' PERM!TCONDITIONS � � <br /> : 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•8810. � I <br /> �� 2.All work shall be performed in accordar.ce with this permit and current City ot Evarelt Design and Construction , <br /> Standards and Specificationa � <br /> � 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> O <br /> ��J f'���-�:�` �/l/,�-� .� . _ F- <br /> � ���' � <br /> 9-z�- � <br /> a � <br /> � <br /> ACK40WL[DGEMENT OF CONDITIONS i . <br /> The undersigned owner/applicant hereby agrees to hold and seve harm- <br /> less the Cily of Everett irom any and all claims for dama;�es, costs, i <br /> expenses. or causes o( action that may arise because ot inslallation i � <br /> and maintenance oi the improvement or other right-of-way use hereto j � <br /> applied (or and further agrees to remove same upon notice Irom the � <br /> Approved lor Construction Date Ciry and to replace public property tlamaged thereby. � <br /> FINAL INSPECTION Date I �.;t� <br /> Approved as Constructed Sic�naWre ot Applicant Date � ,, <br /> WORK AUTHORIZED BY THIS PERMI7 MUST BE STARTED WITHW � - ' <br /> everet[ PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PF.RMIT IS ISSUED AND THEREAFTEF IS TO , ' <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BF � <br /> Everett,WA98201 CANCELLCU BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:255-8810 PROJECT O\�ER 90 DAYS DURATION. <br /> I <br /> ' � <br /> I <br /> � <br />