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Date 1p 6f p <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Pubbc Works Permll a L'/ 6" VT7 <br />Bldg. DeptG <br />* R6/7JG 4 <br />Public Works Fee $ <br />Total Fee <br />Less Appi. Fee Pad $ <br />Balance Due $ /J0 Z —8- <br />5 <br />GUP/V7f yft XY/ YJy—J(Gb <br />_f1f(fY�,)�[NP(J/ <br />Diner Mailing Address Cif Zip Phone <br />1i049_ %d P_i 1MIYf E F veep ? �&& Lc25R 3/G1/ <br />Applicant Mailing Address City Zip Phone <br />11 <br />Describe Proposed Work /1-!--L! d_ Q /n <br />LU <br />Project Address (if known) �L4 r�[ 22 �+ ('� •J, - <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />t� <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 <br />PERMIT CONDITIONS <br />O <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 Specifications. <br />3, Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800-424.5555. <br />PLfr.✓S <br />O <br />I.9i c c7 /O 3/-86 <br />,S j�A,c',Cir/(s ,C!!f/oUT off' j,✓�EE� Ci9,E'.s cfNDE� <br />oia/l Sel-'G L d6 AoalE So Vx To Aeagj <br />CO) <br />C/ / <br />7,ve- C V CS Tv 1JWIVe 0//7- OA✓To 04,eeS Fa,eA/?RD <br />O <br />a <br />FLUArIFISFFECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs. <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />V, it L _. 11_1�lvl_ //-7-A <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />