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� �L/ <br />Date d� � _ <br />Application For <br />P�1�LIC WORiCS PERMIT <br />Print or Type Oni/ <br />� <br />� �j/�� c`7r � <br />C�ty <br />PuoGc worW FCorm�'n � " � ' ��J' _ <br />aiae. Deoi. s-• 7�/� y^ 3� — <br />Public Works Feo $ <br />To'el fee <br />Lov AOP�. Fao PaiE $ <br />Balanco Due $ ,� �� <br />Phone <br />�j��il�%/��f'%.� ---- <br />Applicanl Mailing Address City Zip Phone <br />/ i <br />Describe Proposod Work LNs/fiCi- ;�S L(,%/(�c� 11��1%Lk'�—Tr ��v������ _— <br />Prolect Addre,s (if known) C�'! ' �- "-"'�` - - - — — <br />anach four 141 cooies of plans foi proposed work - Draw to sr,ale and nole lhe following as applica6le: <br />e Property Lines <br />• Oulline and dimensions ot all existing and <br />proposed struc[ures on ihe lot <br />O Existing arti propo<ed utilities <br />• Gentedine of sireet <br />O Indicale North <br />• Show any proposed 9rading changes <br />• Show measur?ments <br />PE^��!IT CONDITIONS <br />1. All calls for inspection shall he made 24 hrs. in advance - phone LS9•881 5. <br />2. All work shall be performed in accordance with this permit and wrrent Ciry of Evere�t Design and Construction <br />Standards and Specificalions. <br />3. Call Location Unde�ground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />FIN ..JSpECTION ; � <br />ApP���ed as Constructed� � <br />everett PUBLIC W0�3KS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, V!A 98201 <br />f�hone: 259-887 5 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The under,igned owneriapplicant hereby agrees to hold and save harm- <br />less the Ciry ol Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of inslallation <br />and maintenanc2 of �he improvemen� or other righPof-way use hereto <br />applied tor and lurther agrees to remove same upon nolice irom the <br />City an�-tcrfepi3�je public �roperty damaged Ihereby. <br />G�_ j �� ,� z <br />Sigitaiu[@�ot Rpplicanl � "�" <br />WOR7rAUTHORIZ�D BY THIS PERMIT NUST BE STAfiTED WITHI�: <br />18(YDA`/S OF DATE PERMIT IS ISSUEU AND THEREAFTER IS ?O <br />B[ DILIGENTLY PVRSUED TO COMPLETION. THIS PEFM1IIT IN,1' BE <br />CANCELL[D BY i I I[ CITY UPOtJ 1NY STnPPAGE GF VJOFK CN TfilS <br />PFOJECT OVER 50 DAl'S DURATIbN <br />� <br />r <br />r <br />H r <br />�.7 n: <br />r� � <br />ff� ' <br />�' <br />�f <br />c <br />3� <br />�' <br />� <br />r, : <br />c <br />�• <br />r :- <br />Hy r <br />K� <br />� ._ <br />� `_ <br />�:7 . � <br />� !` <br />�; : <br />� <br />