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i <br /> Date�y 1 � Publit Works Pnrmit y �-- <br /> r � R�� ��y1 �(� <br /> Application For Blag.Depl.• ___,T <br /> PUBLIC WORKS PERMIT PubTalalFeeFee $ <br /> Less Appt fee Pnitl $ - <br /> Balenca Cue � <br /> Print or Type Gnly <br /> 7�'rn GU �Ic� e ,�OGd.� 1�„h,.c � J2c� Snnl�n:-r� ;,s l., ah�d40 d59-�3�c.;% � <br /> Owner Mailing dress Ciry Zip Phone � <br /> 3 <br /> �S „�e � <br />. Applicant Mailing Address City Zip Phone � <br /> Describe Proposed Work �gl�ll�f� Ti%"� ��N pi' r� e �c�.� o� 1+rtR1A.t (IY7 Msr.t/ y <br /> F� �^ — � <br /> t f' <br /> W � <br /> Project Address(if knownt a � <br /> Altach four(4)copies of plans for proposed work- Draw to scale and note the tollowing as applicable: � � <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 utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIGNS <br />. 1. All calls for inspection shall be made 24 hrs in advance- phone 259•881 5. � <br /> 2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Speciticationa <br /> 3. Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> PU�L�C �c,27,e,E�.s /��"2�rJ�T �!rJT iPFqU�.eE'O S//8/� 7 O <br /> c���`� � I <br /> � <br /> � <br /> �. <br /> � <br /> ACKNOWLEOGEMENTOFCONDITIONS � <br /> The undersigned owner/applicant hereby agrees to hold and save harm- � <br /> less the City of Everet+ from any and all claims for damages, costs, � <br /> expenses, or causes of action ihat may arise because o( installation � <br /> and maintenance of ihe improvement or other righPo(-way use hereto j <br /> applied for and further agrees to remove same upon notice from the � <br /> Approved for Construction Date City and to replace public property damaged thereby. <br /> � <br /> FINAL INSPECTION Date � <br /> Approved as Consiructed Signature of Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIh ' <br /> � 3200 CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO � <br /> Everett,WA 98201 BE DILI6ENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE ; <br /> Phone: 259-8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS � <br /> PROJECT OVER 90 DAYS DURATION. <br /> �+ <br /> I <br /> i <br /> 1 <br />