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_ i <br /> � <br /> ��M�✓. - <br /> p�. ��`� .. L <br />� [� '�— ` <br /> r Date�U� ' � ' a�ou�wa.k:ao� > � <br /> � Application For eiag.oeu�.• � <br /> ��`- PIJBLIC WORKS PERMIT — <br /> Pu�i�cVlorFSFee $ <br /> To!nl Fee <br />�G" <br /> L - Less Ao�l.Fee Paid � <br />� <br /> ' Print or Type Only B„��«o�e $ <br /> � <br />�1 �l�lr' � I�C�C')?/��� 1-I J� l (C��d� �� �� ti'Yt�V� ���1�� <br />�,` <br /> Owner Mailing Address City Zip Phone <br /> N,"?` <br />�i:l` �. Applicant M1tailin9 Address City Zip Phone <br /> I�, <br /> T'_ .���.�tn rr Sy��p <br />`" Describe Proposed Work �_� — <br />�-�,.: <br />��. <br />�' --- W I <br />�:�' - , <br />�"`: <br /> � Proiect Address(if known� � � � <br /> Attach four(4) copies ot plans for proposed work- Draw to scale and note the lollowiny as applicable: � <br /> • Property Lines • Centerline ol street /A � <br /> • Outline and dimensions ot all existing and • Indicale North V� <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 /> S,�I z <br /> k����� � PERMITCONDITIONS <br />;;_� � <br /> 1.All calls for inspeclion shall be made 24 hrs.in advance- phone 259•8810. � <br /> 2.All work shall be performed in accordance with ihis permit and current City of Everett Design and Construction <br /> '?+" � Standards and Specificetions. <br /> t�:� 3.Call Location Undergr�iund Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> 1'' I <br />�` n�t ����,� Q I <br /> �,; y-�-�e <br />:2,-,: �� <br />�'�`'��� � I�— <br /> III � , <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City ol Everetl �rom any and all claims tor dama9es. cosis. <br /> expenses, or causes of action Ihat may arise because of installation <br /> and mainlenance ol �he improvement or other right-o�-way use hereto <br /> applied lor and lurther agrees to remove same upon notice irom the <br /> Approved for Conslruction Date City and to replace public property damaged thereby. ' I, <br /> FINAL INSFECTION Date �I, <br /> Approved as ConsL•ucled Siqnature of Applicant Date � I <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZC-D BY THIS PERMIT MUST BE STARTED WITHIN i <br /> � 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everelt,WA 98207 BE DIIIGENTLY PURSUED TO COMPIETION. THIS PtFMIT MAY BF <br /> Phone�259-8870 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br /> I __ � J <br />