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Date 4/E/84 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Don R. Womack 2717 21st Street <br />Pu�lic Worke Permk • <br />eiea. oeot. e , 84/13201 <br />Pu01ic Worka Fee s <br />Total Fee <br />Less A00� Fea Peid S <br />Balance Due S <br />Everett 98201 252-7464 <br />Owner M2iling Address City Zip Phone <br />Same <br />Applicant Mailing Address City Zip Phone <br />Describe Proposad Work <br />Project Address (if known) <br />Ground floor addition and extend 2nd floor <br />2717 21st Street <br />Attach four (4) copies of plans (or proposed work • Draw to scale and note the following as applicable: <br />• Property Lines • Cenlerline oi sireet <br />• Outiine 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 />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hra in advance • phone 259•881 5. <br />�. All work shall be perlormed in accordance with this permit and current Cily of Everett Design and Construction <br />Standards and Specification�. <br />3. Call Location Undergrow�d 5�•roice 48 hrs. be(ore you dig. TpLL FREE NUMBEF 1-800•424-5555. <br />S <br />J <br />J � `� I <br />� r��� <br />b`�� �V <br />Qµ r/'� <br />�`o Qe� ��bel""�r,� <br />\" �� , a1 <br />,� � �, <br />IApproved for Construction �ate <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMEN7 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 instaltation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and turther agrees to remove same upon notice from tha <br />City and to replace public property Aamaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIIiENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATI(1N. <br />