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�/ � �' / <br />t7are_L�1� <br />Application for <br />[��JBLIC WOF�KS PEP9VIIT <br />P�int or Tyr.e Only <br />�7/Clr�;'�,!);c`S��' �'i� S.r. <br />vvm �"� <br />Address <br />y EL'�: �'�.%1 <br />Pcblm Workf P� �y I I�- <br />Bm9.Deo:+ `'2 <br />PuOhc Works Fae � Q• � O <br />Tolel Foe $ � <br />Leae A00�� Fao Peid S <br />BaiencnDue $ ��' O � <br />�/•1 �, <br />r�<<IlJ��� MeitingAddress Ciry Zip Phone <br />qpplicart <br />DescribeProPosedWork �/�)���[c dS�� ���//)� C(�/%r/'C:E� 1��/!�"r:S/fa <br />�---- <br />73 � Z % � �r• UJ. <br />Prolect Address (it known) <br />Atlach four (4) copies of plans for proposed wcrk � Draw to scale and rote tho lollowing as applicable: <br />O Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />O Existing and proposed �tilities <br />e Centerline of sireet <br />• Indicate Norih <br />• Show any proposed gradina chan�es <br />• Show measurements <br />PE(iM1T CONDITIO�'S <br />t. All calls tor inspection shall be made 24 hrs. in advanCe - phone 2S9•88� 5. <br />2. All work shall be pertormed in accordance with lhis permil and current City ol Everett Desiqn anci Jonsiruction <br />Standards and Speciti��ations. <br />3. Ca1i Loc3tion Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />ACKNOLVLEDGEMENI" OF CONDITIONS <br />The undersigned ownar/apPlicant hereby agrees to hold and save h2rm� <br />less lhe City o� Everett �rom any and all claims loi damages. Costs, <br />expenses, or caus�s uf action ihat may arise becs�se oi installation <br />/� antl maintenanc� �i: the improven�,en: ni other riqhl�of-way use hara!o <br />applied lor antl furiher ayfees to ramove same upon notice Irom the <br />�a �����o replace publy6 prope�ry damaged lhereby. <br />Z3lS <br />FINAL INs�Ecliurv l \ /� <br />App!oved as Constructed v V <br />evere. FUBLIC WORKS DEPARTMENT <br />� 3200 Gedar Street <br />Evcretl, 1"!A 98201 <br />i hone: 259��815 <br />/ <br />.�_ ��-5-� <br />Si arure ol Applicant Date <br />OflK AUTHORIZED 8Y THIS PERMIT MUST EE STAkTED WITHIN <br />180 DAYS OF DATE P[RMIT. IS ISSUED AND THEREAFTEF IS TO <br />BE DILIGENTLY PURSUcD f0 ::OMPLCTION. THIS PERMIT "atl�Y BE <br />GANCELLED BY?HE CfiY UPON ANY S70FPAGE OF VJORK ON LHIS <br />PROJECT OV[R 50 DAYS DURITIC'N. <br />� <br />r <br />