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Date � ��-85� <br />� APPlication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />.s, <br />^J G—//�1 f:rr_ c v� <br />Address ���1' <br />� ��2'—� S.'�U. LSi <br />Address ��Y <br />PUEIiC Works Pe�mit + u'� � <br />ama. oeo�.• 9,�//�3 i/ <br />. <br />PubliC Works Fee s <br />To�al Pee " <br />�i�»ppplFeePaid S <br />e��ienca Due S �� OU <br />c�%a77-.�'47'�'%a�%3 /S�'r%� <br />Zip Phone <br />Describe Proposed Work <br />— (.�'� TG.C/.<'S AOT4'��NT f�/'O.�-',E�' �7-,�• �'a•uSi�� <br />G'pyG�c - CA.eD - GC:C�C r�L•/i�s� �S ^eic'/� --/-r/iT.si �:TEE� CQifivs��_ <br />n_�.._� �^�..:oc �' <br />Project Address (�i known) __ ����' <br />Atlach four (4) copies of plans for proposed work <br />Appro��e!t <br />Draw to scalq and note the tollowin9 as applicanle: <br />• Property Lines <br />• Outline end dimensions of all existing and <br />propo:ed structures on the lot <br />• Existing and proposed utilities <br />• Centerline of street <br />• Indicate North <br />• Sho N any proposed grading changes <br />l� Shov: measurements <br />PERMIT CONDlTIONS <br />t. All calis for inspection shall be made 24 hr�. in advance • phone 25�-881 5. <br />2. All work shell be performed in accordance with this permit and current City oi Everetl Design and Construclion <br />Standards end Specifications. <br />3. Call Location Underground Service 4b hrs. before you dig. TQLL FREE NUMBFi; 1-800•42'.4•5555. <br />y /1�/N�y�UM fiCCEr'Td!3Gc� ���%c�LTc��RL SECTioi✓ <br />FevP P4.�.Ci.r/b c�'rs SNGc.e dE �' ���oinv,a C.Te-D� <br />O� <-'c'sI SS � f� �� � S.Js/�1 G T f�lACEd OYE,[' S! �• <br />�C�/ri`��e'TE� :)� C•C'GiSs/E-O SC�:e_FaCi�t/C• TF' Cn/1,�TSi� <br />FINAL INSPECTION v \ <br />Appwved as �oi,slructed <br />everett PUBLIC WORKS DEPAfiTMEN <br />� 3200 Cedar Street <br />Everetl, WA 98207 <br />Phon�_: 259•8815 <br />Date <br />W <br />H <br />� <br />� <br />z <br />O <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/2pplicant hereby agrees to hold and save barm- <br />less the City of Everelt from any and all claims for damages, costs, <br />ezpenses, or caus2s ot action that may arise because of instailation <br />a�id maintenance ot lhe imp�ovement or olher right�of•way use he�eto <br />applied for and Wrther agrees to remove same upon notice irom the <br />Cily and to replace public property damaged thereby. <br />r,��.� ,,.� �, >,,�, <<, :,,r <br />� i. ���/ ` � �-� ���' S ~ <br />SianaWre of APPlicant <br />- Date <br />1�OHD YSTOFRDATE PERMIT ISEISSUED AND THEREAFTER ISHTO <br />B[ DILIGENTLY PURSUED TO COMPLETION. THIS PERMIi MAY BE <br />C;ANCELLED BY THE CITY UPON ANY STOPPAGE OF WJRK ON THIS <br />PROJtCI� OVER 90 DAY; DURATION. <br />z <br />0 <br />--� <br />F. <br />C'� <br />m <br />