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� <br />TYPE OR PRINT ONLY <br />ApW�catlon Fw <br />C WORKS PERMIT <br />PUBLIC 1NORKS DEPAFi'TMENT <br />321Y1 Cedar Street <br />Everett, WA 98201 259-8810 <br />Data 10/2/.^,6 <br />Publk Works PurtnN N � ����� _ <br />euilding Permit M 5309a <br />Public Works Fee S � <br />NRWKTRR SCOTT PO ROR 17999 MTTT fRFFX qA0R9 959 9976 <br />Owner MailingAddress Ci' " - - - �• — <br />ApPi�cant Mail(ng Address Ci <br />Describe ��roposed Work CONVFRT SFR To n rP Fx <br />PROJECT ADDRESS (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the tollowii <br />•Prope�iy Lines 'Outline and dimensions of all existing and proposed siructure <br />'Centerline of street •Indicate NoAh 'Show any proposed grading cha� <br />DO NOT WRITE BEL( <br />1N�olly f��na�� <br />�d�(s� ha�vc aNnw <br />�np�c�� ��h a�►+c6 <br />ho�d 4�rvxlr,c� �r►�� <br />�tGr -fa iSsw�lGG O'F ��'� <br />PERMIT CONDITIONS: <br />1. All calls for inspection shall be made 24 hours in advance - phone 259-8810. <br />2. All work shall be pertormed in accordance with this pemiit and current City of Everett Design and <br />Construction Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-4245555. <br />�• �Rf"r�iV �d� �fi O-F�'S-�'f�z'f' �-i/ ✓'i',;Vl(1 `�''rzl�! <br />J <br />G���d No� 1,fla�_ <br />� 5 ��- p;an <br />5• v� grzzc� �� se�rv; ce -izs m��tered se�►v i cc. <br />�� <br />ved for stn�c6 n D e <br />i <br />FINAL INSPECTION Date <br />Approved as Constructed <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The underslgned ownar/applicant hereby agre.�s to hold and save harmless <br />the City of Everett from any and all claims for damages, costs, expenses, or <br />causes of action that may arise because of installation and main!enence of <br />the impiovement or other right-ot-way use hcveto applied for and furtheragrees <br />to remove same upon notice from the City and to replace public propeAy <br />damaged thereby. <br />Signature of Appiicant Dete <br />WCRK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN 180 DAYS OF DATE PERMR IS ISSUED AND THEREAF7ER IS TO BE DILIGENTLY PURSUED TO <br />COMPLEf10N. THIS PERMIT MAV BE CANCELLED BY THE CIN UPON ANY STOPPAGE OF WORK ON THIS PROJECT OVER 90 DAYS DURATION. <br />