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i: � <br /> , <br /> � .; <br /> ; <br /> , i <br /> � <br /> ( j <br /> Oate�� � � � P„��,�wo�.�Pe,�y�/ � <br /> APPlicalion For �inp oen� • _S1J_��-__ � .:„� <br /> PUBLIC WORKS PERMIT P°°���µ�°�°SF�r ---- I � <br /> To�.,�F�� s_ <br /> Less ancd Fr,e PaW 5 I <br /> Print or Type Only ���:��=�•o��� s _ " <br /> � <br /> ����!dd-L61�! 1` r n'?l�� .�" ' �.� ���� ����CJ � �r� —o'o{�� III :� <br /> Owncr Mailing Address Gty Lp Phone �_��,� <br /> ��-�E ����.Si- I lal � i� �.�: �����1.�5 �Qa � I <br /> Applicant Mailing Address Gity Zip Phone �� - <br /> ��1����_� i�rii�Y� �2i v�.1i�x1�� I, i <br /> Descnbe Proposed Work �. , <br /> Project Address lif knownl /�� �� .� �L <br /> ■ <br /> Attach four�4� copies ol plans for Proposed work� Draw to scale and note the followinq as applicable: � <br /> • Property Lines • Centcrline of street � <br /> • Outline and dimensions of all existiny and • Indicate North <br /> proposetl struclures on Ihe lot • Show any proposed grading changes <br /> • Exi>ting and proposeA utilities • Show measurements � <br /> C�O NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIUNS <br /> 1.All calls for inspection shall be made 24 hrs.in advance- phone 259•881 d. � <br /> 2.All work shall be performed in accordance with this permit and w«en!Ciry o(Everett Design and Conslruclio� <br /> Standards and Specifications. <br /> 3.Call Location Underc�round Service 48 hrs.before you di9.TOLL FREE NUMBER 1•800•424-5555. � �, <br /> ��.C ��'�i�' �__'[�'/_�=� ����. �/[� ����f/ �c �'('[yCC(� � ' <br /> � i. <br /> �� �%_�`/�����/-- � <br /> ! /C---;�% � <br /> O <br /> a <br /> ACKNOWL[DG[MENT OF CONDITIONS <br /> i hr undersi9ned owner/applicant hereby agrees to hold and save harm- ' <br /> less the City ol Everetf hcm any and all claims for damages. c�sts. <br /> expenses. or causes of action ihat may arise 6ecause of instslla�ion <br /> and maintenance of the improvement or other rigM-of-way use hereto <br /> applied for and lurthm agrces to remove same upon no'ice from ihe <br /> Approved for Construction Uate Ciry and to replace public property damageA thereby. <br /> FINAL INSPECTION Date — <br /> Approved as ConsVuc(ed Signa�ure ol Applicanl Date <br /> everett PUBLICWORKSDEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarStreet 180 DAYS OF DATE PERAIIT IS ISSUED AND THEFEAFTER IS �O <br /> Everett,V�'A 9R201 B�5 DILIG[NTLV PURSUED TO COMPLETION. THIS PERMIT MAY ElE <br /> Phone:25^�8810 CANCELLEU BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />