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� <br />� R q C/ <br />� �a�e ���-�� PubllcWurksPermi�3� < J <br /> I Application For eme�oeu�,.• .3 ,.3�i <br />' PUSLIC WORKS PERMIT P°°��°W°�k=Faa <br /> Tolal Fee $ �' �� <br /> Lesa Appl Fee Peitl S �l�c-�� <br /> Balance Duo $ d"'C/• V l7 <br /> Print or Type Only �5��� <br />� I_ . , . , <br /> iLr �S ��ir/<<�� 1�!�c �,���C., . , ,. �-[��/ ��'� /ii�;<< !�'if�Y (-�i��:.�:� �%� �:j;�;����/ _���,� �/�y7- <br /> Owner MailingAddress City ' Zip Phone � <br /> I /�1/!d f/G�. <br />� Applicant Mailing Address City Zip Phone <br />�I De�cribeProPosedWork �ti5%iti�c c%`, � ��i/UC /j"v��/�G-iC- .i�. (C'��. CL//��/ <br /> W <br /> Prolect Addres�lit known) �n% ��� �"�"��/`t�( ,1i� /`�iflTC.e �� � � — ¢ w� � � <br /> � <br />, Attach four(4)copies of plans for proposed work• Draw to scTle and note t!ie following as applicable: � <br />� • Property Lines • Centerline ot street � ' <br /> � Outline and dimensions of all ezisting and • Indicate North '. <br />� propoced structures on the lo! • Show any proposed grading changes <br />' • Existing and proposed utilities • Show measuremenis � <br /> i <br />. DO NOT WRITE B�LOW THIS LINE O � <br /> PEpM1T CONDITIONS ' <br />, 1. All calls(or inspection shall be made 24 hrs. in advance- phone 259•881 5. � ' <br />� 2. All work shall be perf�rmed in accordance wi!h�nis permit and wrrent Gity of Everett Design and Construction '� <br />� Standards and Sper.ifications. �, <br /> 3. Call Location Underground Service 46 ius. before you dig.TOLL FREE NUMBER 1•S00•424•555F. � i <br />' .I i.�fQf.� be I� easeMP� i� KO� � �e CIPa,r:-.Sf` p .. <br /> y <br /> �. ��us}• w�er 5e�,,�c� v <<lvc box � -.�,�G,1 �o�- � r���� � i <br /> � ; <br /> � <br /> � �, <br />; � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> 7he undersigned owner/apPlicant hereby agrees to hold and save harm- <br /> less the City ol Everett from any and all claims for damages, costs. <br /> �' �/J!� — expenses, or causes of action that may arise h9cause o� installation <br />� �/��� and maintenance ot ihe improvement or other ri ht•o4wa use hereto <br /> applied Jor and further agrees to remove s�me upon notice from the <br /> Ap roved for Co�istruction Uate City and t replace public roperty damaged thereby. <br /> �r.: l�� ��% �� _ - /'� /, <br />. � • 3�,�/��v , _, <br /> ��A -� iL� .� ;� :� �� ; <br /> FINAL �'�ION l\ Date <br /> Approved as Constructed V Signatu e of Applicant � � Date <br />' everett PUELIC WORKS DEPARTMENT WORK AUTHORIZED BS' THiS PERMIT Iv1UST BE�STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TU <br /> � 32�0 Ced•r_r Streei BE DILIGENTLY PURSUED TO COMPLETION. THIS PEFlMIT MAY BE <br /> Everett, 6'/A 98201 CANCELLED BY THE CITY UPUN ANY STOPP.4GE OF WORK ON THIS <br /> Phone: 259-8875 PROJECT OVER 90 DAYS DURATION. <br /> ( <br />