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�" �ate Public Works Peemii a v 7'��''.7��3�, <br /> Bldg.✓ePL+ ___i�% — "�— <br /> - Application For <br /> PUBLIC WOF�KS PERMIT PuoTolalFeeFee � <br />�� .. Less Appl.Fee Paitl S "� - <br /> �/, ���� <br /> � � Balance Due $_�^'�� <br />'` Print or 1'ype Ji�iy <br /> ,� �vr�;��� 7/3 S� �.%�°��TI/l�a//IG�Ni °�E32oF3 3,5:3 - �o,s'oo <br /> Owner Mailing Address City Zip Phone <br /> _���n� <br /> , Applicant Mailing Address Ciry Zip Phone <br />- _ Describe Prcposed Work ����J' C_�//l i C Q�Y9!/ __ /�1b9'�/10 <br /> t _ -- W <br /> � Project Address(if known) �� l� � tE � <br />. � Attach four(4)copies ot plans for proposed work• Draw to scale and note the following as applicable: � <br /> • Property Lines . • Centerline ot street � <br />,�,.. • Outline and dimensions of all existing and • Indicate North I <br /> .. proposed structures on ihe lot • Show any proposed grading changes <br /> .� • Existing and proposed utilities • Show measuremenis aq <br /> W <br /> ` DO NOT WRITE BELOW THIS LINE O <br /> � PERMITCONDITIONS <br />''� � � 1. All calls tor inspection shall be made 24 hrs. in advance- phone 259-881 5. � <br />�R��-, �: 2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />[�=� .. Standards and Specifications. <br /> j�r 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> f; <br />'; ,;� `'�� �r<<--���✓�'s ��� / Z-8 -e� � <br />� <br />� ; <br />'.:` � �� �'�' �)�v�i�/�_�n V♦ <br />; � �j t - ,--��-y' , <br />�; � " � G' "/�y' / O <br /> r .�.� � �- �- a <br /> � <br /> ` C� r <br />� - �.�� <br /> � <br /> A KNOWLED MENTOFCQNDITIONS ' <br /> The undersign d wner/applicant hereby agre:es to hold and save harm- <br /> less the City of Everett irom any and all claims tor damages, costs, <br /> ��> - / j expenses, or causes of action that may anse because of installation i <br /> j�� ., � � and maintenance of the improvement or other right-ohway use nereto �, <br /> --�� � �' %� �� applied for and further agrees to remove same upon notice from the '� <br /> Ap roved for Co9 ruc�i � Date � City and lo replace public property dama9ed thereby. . <br /> i � <br /> ` / I <br /> FINAL INSPECTI N Date ' � <br /> Approved as Consiructed Sic�na ure of App icaM Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT �S ISSUED AND THEREAFTER IS TO <br />� � 3200 Cedar Street BE DILIGENTLY PURSU_D TO COMPLETION. THIS PERMIT �dAY BE ' <br /> Everetl,WA 98201 � <br /> Phone: 259-8815 CANCELLED BY THE GTY UPON ANY STOPPAGE OF WORK ON THIS ,' <br /> PROJECT OVER 90 DAYS DURATIO'J. �—� <br /> i <br />