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Datas �/G� . <br />Application For <br />PUBLiC 1�/ORKS PERN1; �' <br />Print or Type Only <br />�IG�J_S /; <br />Owner <br />F)�.1�/��C�� <br />qpplicant <br />j ��> `5��: C' i�f-Ji'%% /Li/,"'.%( <br />Mailing <br />Address <br />PUUecFoircsPem t �-�� p��� " _' <br />Bltlg-Dept e ���� 3 1-R-� <br />PuOI¢ works Fee S�„�J Q p <br />Total Feo <br />Less FpPI. Feo Paitl �S — <br />Balonce Ouc 5 �-0 ' �� ___ <br />G 9�io <br />�. , ,,� i:,1,�0`! ,:�`� $--l%% �= <br />�%f� �/ i'sl �':7't i <br />Z{p rnone <br />City Zip Phone <br />�1 � 'rt'��c="rlr✓� ��E-�c- y�,c',d�=;�c?-Y <br />Describe Pwposed W�rk �N Si��`C �� � — <br />Frolecl Addrecs (il known) � � z <br />AUach four (4) copies of plans for proposed work - Draw te scale and note lhe followinq as applicable: <br />• Property Lines • Centerline of street <br />9 Outline and dimensions ol all existing and • Indicalz �orth <br />proposed slructures on the lot • Show any proposed 9rading chan92s <br />• Existing and proposed utilities e Show measurements <br />TH <br />PERMIT CONDITIONS <br />1. 4II calls tor inspection shall be made 24 hrs. in advance - phone 259$Bi 5. <br />2. All work shall be performed in accordance with this permil and current Ciry ol Everett Design and Cons(ruction <br />S�andards and Specifications. <br />3. Call Location Underground Service 48 hrs. 6efore you dig. TOLL FREE NU7dRER 1•800-424•5555. <br />.-.��— <br />` ���� �� <br />� <br />FINAL INSPECTION �\ <br />Approved as Constructed � <br />eve�ett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everet�. �VA 98201 <br />� P�onc:259�8&'1�i <br />r� <br />J �/U " <br />�:` <br />�" <br />ACV<NOWLEDGEMENT OF GONDITIONS <br />The undersi�ned owner/applicant hereby agrees to hcld and save harm- <br />less the City of Fverelt from any and all claims for damages, cosis, <br />expenses. or causes of action that may arise bacause ol installation <br />� and maintenance of lhe improvemen� or ofher rlght-o4way use hereto <br />appf for and further jgraes to remove same upon nntice from the <br />/ ity an to replace public property damaged thereby. <br />. f,.�i� � �� l� . , ! �/ n �l <br />� _. . � I � Date <br />Sigr(alure of AppliCant <br />WORK AUTHORIZED 8Y THIS PCN�aIT MUST �E STARTED WITHIN <br />180 DAYS OF DATE PERMIT I� ISSUED AND THEREAFTER IS TO <br />BF DILIGENTLr PURSUED TO COMPLETION. 1rIIS PERMIT MAV BE <br />CANCELLED BY -�HE : ITV UPON ANY STOPPAGE OF WORK ON THIS <br />�, PROJECT GV[R JO DAYS DURATIOU. <br />�, <br />-y .: <br />H .. <br />� '. <br />7 � <br />C: C <br />i <br />�G ' <br />r; - <br />O i <br />C <br />r'- . <br />� <br />7 <br />� <br />� <br />S: , <br />;J , <br />