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Date��� ��� <br />Applicalion For <br />PUBLIC \NORKS @�:'F�IVlIT <br />Print or Type Only <br />gv /( �f <br />Pu�Lc Slo�k, ?ormil r — <br />L/ Sd <br />emq o�o�� _ — <br />Public Works F�e S `� p, Q � <br />Tolal Fee <br />Less ApPI. Fee Paid S — <br />Balanta Oue S �O• � � <br />9xr=� <br />' %>UP. Y`iG� .l�'�E"/+�t' E�/ �%s��:t C��%�% (�:�7:/CC.'%�� ��S'LG �_'>=']� —[�!�`-t-_. <br />(���5 �/%l�'� <br />Owner Mailing Add s -- C�.�y Zip � Phone <br />Applicant <br />i,ny <br />Zip Phone <br />ir, , _ <br />�iilr�, o�S l��'i�)F- �%i�� ����rE� - k'iuE=�c % . <br />Describe Proposed Work�N T � <br />��//�� co; <br />Project Address (if known) � LL�— � �i� G"U_----- — <br />Attach tour (4) copies of olans tor nroposed rrork - Draw to scale and note the .�liovru��,,; as applicable: <br />• ProPerty I.ices <br />• Outiine and dirrrensions of all ex�sting and <br />proposed strucWres on the lot <br />s Existin!7 and pronosed utilities <br />O C,enterline of street <br />i Icdicale North <br />• Show any proposed grading chan�,7es <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls tor inspection shall be made 24 Fes. in advance - phone 259•881 $. <br />2. All work shall be pertorneo in accordance v:ilh this peimit and current Cily ol Everett Design and Construction <br />S!andards and Specitications. <br />3. Call Location U�iderground Service 48 hrs. before you d�9. TOLL FREE NUMBER 1•800•424•5555. <br />.f-/�'-� <br />�iFY���vc'v fo\ on5}(uction uale <br />( ��� V 1��,,.,o��. ,:�.�� �� ��-��� � <br />FINAL INSPECTION I\ , Date <br />Approved as C _nstructed \ � �; <br />everett PUBLIC W KS DEPARTMENT <br />3200 Cedar Slreet <br />G Everett, WA 98201 <br />Phone: ?9'�E1615 <br />AGKNOWLEUGEf1[i�T Ot GONDITIONJ <br />Tha ur�-krsi9n�d owner/apC��cant hereby agrees to hold and save harm- <br />less Ihc• City of E��ere', irum any and all claims for damages, cosls, <br />expenses, or causes o( action �ha� may arlse because of ins�alla�ion <br />and maintenence ol the improvemeni or other righPof-way uce hereto <br />appljod-t°�r and furlher ayrees to remove �ame upon notice trom the <br />Citv and td reolace pyblic properly damaged thereby. <br />_ ���1 i i f�'� � <br />; 1y-b� <br />SigqS�ure o( Applicent "'""' <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />.I80 DAYS OF UATE PERMIT IS ISSUED AND THEREHFTFR IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLEU BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJ[CT OV�F 90 DA'iS DURATION. <br />�: <br />t-: <br />