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PuoncNb�ksPerm�t7 � � � � <br /> Date �� s � aiaa.oeac= 3 ^� 7/ <br /> Applicalion For <br /> Public Worksice g 1� . �� V <br /> p�B�,O� �11/ORKS PERt�IIT TolalFee <br /> i.��s noo� Fec rn�d 5 <br /> 0atance Oue S ��� � O <br /> Print or Type Only �C ��� <br /> r _ ' •' �' <br /> `' ,�, r,5_31 /U �� f,v� d.v��/'t%� ���s 3<.:{ a S �- � f <br /> �7.nt;.r �i L ��n.-+.�� Phone <br /> Owner <br /> Mailing Address Ciry Zip <br /> ��Au�eP � City Zip Phonn � <br /> qpplicant Mailing Address <br /> Describe Proposed Work <br /> /�l i.=t✓ �,R.�i+.GiE — <br /> ----�— <br /> � <br /> ia �:.: �c. �� � <br /> �,�5-� I �u '-- �r�cf �>_��c= � iT • � _ <br /> Project Address(if known) `i <br /> Attach four(4) copies of pl2ns for Proposed work- Draw to scale and ncte lhe tollowir.g 2s aoplica6le: � <br /> O Property:ines • Centerlina of slreet <br /> • Indicate Norlh <br /> • Oulline ar.d dimensions ot all ezisting and O Show any pwposed 9rading char�ges <br /> proVosed struGures on the lot � ghuv measurements � <br /> ! Existing and proposed ut�lities <br /> DO NOT WFITE BELOW THIS LINE � <br /> PERMIT CONDITIONS � <br /> 1. All calls for inspection shall be made �4 hrs. in advance- phone 259•SF31 5. <br /> 2. All work shall be performed in accordance wi�h this permit and current Ci�y ol Everett Design and Consir�ction <br /> Standards and Specificatiuns. � � <br /> 3. Cali Location Underground Servicc 48 hrs. belore you din.TOLL FREE NUMBER 1-800•424•5555. <br /> r <br /> � �: <br /> �/ <br /> � H '- <br /> �� . <br /> � . <br /> � � <br /> C _ <br /> � � r <br /> N � <br /> � . <br /> rr <br /> ACKNOWLEDGcMENT OF CONDITIONS �; <br /> �� <br /> 7he urdersiqned o�vner/applicanl hereby agrees to holtl and save harm- ,� : <br /> __ — Icss the C�ty of Everett irom any and all claims lor damages, costs, <br /> i������ enPenses. or causes ot action that maY arise bec;:use of installation �-` , <br /> � ///U— c 3 and maintenance of ihe improvement or other righi c4-way use hereto r� �� <br /> � applied for and turther agrees lo remove same upon notice trom the <br /> Date City and to replace pu lic proPerty dama�ed thereby. �-+ �� <br /> q ve lorn struction , -= . <br /> V— '� C / L � ' \ `� ~ <br /> � � � ✓C� r <br /> ` ate � Date - <br /> FINAL INSPEGTION Signature of Applicant — <br /> Ap�.roved as�onslrurted \VORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PU6UC V�ORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TC . <br /> 3200 Cedar 3lreet 8E DILIGENTLY PURSUED TG C061PLETION. THIS PE"'MIT tv1AY BE <br /> � Everett,WA 98201 ChtdGELLED 3Y TV-IE GIT'f U°ON �N1�' STOPPFGE OF WORK O�THIS <br /> Phone: 259�k381E PRCJEOTOVERsi� U;:���� iIURHT10Id. <br />� <br /> — _ � <br />