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� �� <br /> H , <br /> C> H �,�' ar — — I <br /> t"�y Date�0 P��,�wo«s P�•� �. _ <br /> �-i '.il eiae oeo��+ -- — <br /> y H Applicalion For <br /> �H� PUBLIC W�RKS PERMIT P°°'�°w°""°° <br /> To�al Fee 5 �. <br /> y LessAppL Fee Paid $ '. <br /> H <br /> �C � 9alanceDuc $ ( <br /> C+1 Qy � Print or Type Only <br /> OH <br /> ��g t�l�a���inv� Fn���_,'�' � �E`�y �--,'�«�iilP �G��o <br /> x H Owner � Mailing 4ddress Cdy Lp �f Phone�� I <br /> H !, J q �7 � ���(] � 1 <br /> tyyy I�'`�U—/�^l� !OV X �� ��r�U��I� [-�� /����I[��� I <br /> � �y A4P��cant IAailing Address � ✓ Z�P Phone <br /> � y� Describe Proposed Work �_ <br /> H O Cn <br /> — — � ; <br /> Project Atldress(if known) I I � I� — � �� <br /> Aflach four 141 copies of pians for proposed ,vork� Draw to scale and note Ihe lollnwing as applicable: � j <br /> • Property Lines • Centerline of slreet /A <br /> • Outline and dimensions of all existing and • Indicale North V� <br /> pmposed slruciures on Ihe lot • Show any proposed c�radinp chan9es <br /> • Cxisliny and proposeJ ulilities i Sho,v measurementc M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> � 1.All calls lor inspection shall be made 24 hrs.in advance�phone 259�8810. �\ <br /> '�1 2.FII k�ork shall be pedormed in aa:ordance with this permit and current Ciry ol Everep Design and Consiruction ♦ <br /> ' Standards and Specitications. <br /> ' 3.Call Location Underqraind Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. � I <br /> � <br /> i I ��T ��' . 3�s � i, <br /> 1 v�� � I <br /> � � <br /> ►-� a <br /> �_� <br /> _� <br /> ' ACKNOWLEDGEMEIJT OF CONDITIONS <br /> The undersi9ned owner/applicant hereby agrees to hold and save harm� <br /> '�' — less �he City of Everett from any and all claims br damapes, costs, <br /> expenses, or causes oi aclion Ihat may arise because of installation <br /> ' ' and maintenance of the improvement or other nght�of�way use hereto <br /> � applied for and further agrees to remove same upon nolice �rom Ihe <br /> Approved lor Construction Date City and to replace public property damaqed thereby. <br /> FINAL INSPECTION Date Dale <br /> Approved as Constructed Si9nature ol ApPlicant <br /> WnRK AUTHORIZ[D BY THIS PERMIT MUST BE 5�1'ARTEC) INITFfIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. THIS f'ERMIT MAY BE <br /> Everetl,WA 98201 CANCELLED BY THE GTY UPON ANY STOPPAGE OF WOHK ON THIS <br /> Phone:259�8810 pROJECT OVER 90 DAYS DURATION. <br /> i <br />