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� / <br /> T _ <br /> 11 <br /> r <br /> '1 <br /> r 1 <br /> Pubiic Warb Permil• <br /> Date <br /> eiap.Deo�.• <br /> Application Fo� � <br /> PUBLIC WORKS PERMIT P°°°`"'°""Be <br /> ,o�a�Fao S <br /> . <br /> Less Aoo�Fee Paia S <br /> � �a„��ao�a $ <br /> Print or Type Qnly 't <br /> c / /� / fh [� <br /> � ��111rLL' y )C `�IP / ��C �" ��O �I 4 fV�/C� IIf� ' � Pho� �.l ' /s.�� <br /> Owner <br /> J Mailin9 Address ���Y Z�p <br /> Ac� C � �- �s"1Z `� s - -� �z-,� ��,� � , 2<� .� � �v� � <br /> Applicant <br /> Madm�Address Cdy Zip Phone <br /> Describe Praposed Work <br /> /J.' 7/ _,i r �� " ` <br /> )iV '�C <br /> W -- <br /> Project Pddress(il known) — � i <br />� <br /> Attach tour(4)copies ot Plans for proposed work- Draw to scale and note the lollowing as applicable: � <br /> • Prope�ty Lines • Centedine of streel <br /> a • putline and dimensions of all existing and • Indicate North <br /> i ll Show any proposed grading changes <br />� proposed sirucWres on the Ict • Show measurements M <br /> 1 • Ezisting and praposed u�ilities W i <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � � <br /> 1. All calls tor inspection shall be made 24 hrs.in advance-phone 259•881 5. <br /> 2. All work shall be performed in accordance with this permit and current City ol Everett Desi9n and Consiruction <br /> Slandards and Specifica�ions. � <br /> 3. Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424•5555. <br /> i,/p/K-s � '` / O � <br /> �wb�,� � ��5u��� a� ' <br /> , F- <br /> l�° �� � ' N ; <br /> � ���3 0 � <br /> �� a <br /> I <br /> ACKNOWLEDGEMENT OF CONDITIONS � <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less lhe City ol Evereti irom any and all claims for damages, costs, <br /> expenses, or causes ol action �hat may arise because of installation , <br /> and maintenance ol �he impiovement or other righirot-way use hereto , <br /> applied tor and further agrees lo remove same cpon notice irom lhe <br /> Approved for Consiruction Date Ciry and to replace public properry damaged ihereby. i <br /> � � J � <br /> Date � Date <br /> FINAL�NSPECTION SignaWre of P icant <br /> Approved as Constructed <br /> W017K AUT RIZED BY THIS PERMIT MUST BE STARTED WIT <br /> 0 everett PUBLIC WORKS DEPARTMENT 1d0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO � <br /> 3200 Cedar Sireet BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BV THE CITV UPON ANY STOPPAGE OF WORK ON THIS f <br /> Phone: 259�8815 PROJECT OVER 90 OAYS DURATION. <br /> L � <br />� <br /> L <br /> J <br /> � <br />