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, <br /> � � � � <br /> o � x � <br /> ' yy I <br /> H�� <br /> � i <br /> �yy� Date /'2��� � TO �nsT►NG_ �� �3 PubircWo�ksPetmi�• 9 � <br /> � ,K„r eioc o�m.. <br /> p � Applicalion For <br /> � H pUg�IC WORKS PERMIT F�O�sWorMSFeo $ <br /> � �g to,a�Fee <br /> p� � Less ApPI.Fee PaiE � <br /> H Balancc Due $ ��� —' <br /> a y� Print or Type Only <br /> t� � <br /> NH <br /> gCVHi r� ,-� \/O�-. �--Vw� b� � 3X2-I 26 'F�A�-P r.rPNLV�-ar ��96d7L� <br /> �� Owner Mailing Address Cny Lp Phone <br /> �� �WI �eJ �.cc � �oZz� / 7� Av�- A���+-,nTo-` 9 �'lz� Y7s'.��°`/ <br /> � Applicant Mailing Address City Zip Phone <br /> � ✓i.f.w vr S: T{AY� lC f C�f- 1�,Cr[ �/ l��Gl/L <br /> 1 <br /> Describe Pwposed Work ��^^n-�'e 1 ��p� � � <br /> 11� 4��i bU �KYh � � <br /> \ C� la�A-\f � SG /4V�'�' h^�'1 C.•g ' <br /> W <br /> Prolect Adtlress(if known) � 6 �" � �� ` _ � <br /> Attach four(4)copies ol plans lor proposed work- Draw to scale and note�ne following as apUlicahle: � <br /> • Property Lines • Centerline ol slreet ♦A <br /> • Outline and dimensions ol all existing and • Indicate North V� <br /> . proposed struUures on the lot • Show any proposed grading changes <br /> '�1 • Existing and proposed utilities • Show measurements M <br /> 1_' DO NOT WR!TE EELOW THIS LINE W <br /> PERMIT CONDITIONS O <br /> '�� 1.All calls tor inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2,All work shall be pedormed in accordance with this permit and current City of Everett Design and Consiruclion <br /> 1 ' Standards and Specitications. <br /> � 3.Call Location Underground Service 48 hrs.before�iou dig.TOLL FREE NUMPER 1•80U•424•5555. � <br /> � �f, �l-5 ��� a��rove���a�-i da� 1l� 1- 13-q3 O <br /> 1_ <br /> '� �" <br /> 1"_ (/� <br /> - <br /> '� 0 <br /> -I a. <br /> - <br /> I"/1 <br /> '�1 ACKNOWLEDGEMENT OF CONDITIONS <br /> �-- - The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the Gty of Everetl Irom aoy and all claims for tlamages, costs. <br /> expenses, ar causes of action tha! may arise because of installntion <br /> ��� I/�,I�/'n� / �J ���L�2 and maintenance of the improvement or other righbo4waY use hereto <br /> r2� �vL I.,���— % -� applied for and lurther agrees to remuve same upon notice irom ihe <br /> Ap roved lor Con Kuction . Date City and to replace Uublic properry damaged thereby. <br /> �` r��� a �/ �3 ����i I'= �V(?�c>-- <br /> FINAL INSPEC710N Date l . <br /> Approved as Constructed Signature of ApplicaM Date <br /> � WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED W�THIN <br /> _^ PUBLICNIORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Sireet BE DILIGENTLY PURSUED TO CG�:PLETION.THIS PERMIT MAY BE <br /> �,/ Everett,WA 98207 I CANCELLED BY THE qTY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURAT!ON. <br />