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Date�� <br />Application For <br />PU�3LIC WORK� pERNiIT <br />Print or Type Only <br />lG�[�S �l)7 -G-S J��Jt, <br />��(iNE� �� <br />Applicant <br />,SL- ( <br />Mailing <br />Mailing <br />i/ /ilf)[c 64'{"�� /(�C�,C''C`l/ �� <br />City ZiP <br />City Z�P <br />/n1 iArc �.�5� Cdii�'r l�n,Y�eCTc .D,c��✓<-u,. <br />Describe Proposed Work 5 � <br />Pu�lic WorMe Permit • �`/ ZU Z <br />eme� oeot • �`3S <br />PuelicwukeFee ; O.Oo <br />Toial Faa s <br />Leee ADF�- Fna Paid S -- <br />eaia�caouo $ a0.00 <br />%0� <br />3s:r= �/��y� <br />� � — � .; ----- - <br />—75 0 8 "1 + �� c �>«� �:_ _._, `Fs �: �� <br />Pro�ect Address (if known) _(— <br />Attach lour (4) coo��s uf plans for propesed work - Draw to scale and note the lollowing as applicable: <br />• Property Lines a Centerline of sireet <br />• Outline and dimensions of all existin9 and • Indicate North <br />proposed structures on �he lot O Show any proposed grading changes <br />• Existing and proposed utilities e Show measurements <br />PERMI,-CONDITIONS <br />1. All calls for insPection shall be made 24 hrs. in advance � phone 25�•8$1 5. <br />2. All work shall be performed in accordance wi;n this permit and cu« nnt City ot Everett Design and Cons�ruction <br />Standards and Specifications. <br />3. Call Location Underground Service •t0 hrs. belore you dig. TOLL FREE NV�IRER 1-800•424-55�5. <br />/. <br />r�_..�/ ��i��--l.� ' o'� i' - O � <br />--Rpproved for Cons�r c�n Date <br />a9-1�FINAL INSPECTION Date <br />Approced as Constructed <br />everett\1 PUBLIC WORKS DEPARTMENi <br />� I 3200 Cedar Street <br />�I EveretC 4NA 982C7 <br />JPhone:259-8915 <br />ACkNOWLEDGEMENT OF CONDITIONS <br />The undersiyned owner/applicanl hereby a9rees to holC and save harm� <br />less the City ol Everetl from any and all claims for damages, cosls, <br />expense>, or causes ui action that may arise because cl installation <br />and main�enance of lhe improvement or other righhof-way use herelo <br />for and further agrees to remove same upon notice Irom ihe <br />City an to replace pub c properry damaged ihereby. <br />�� � 6 �� � _ <br />Si ature ol Appli t ale <br />� ORK AUTFIORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PEFMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGEIJTLY PURSUED TO COMPLETION. THIS PERMIT tdAV BC <br />CANCELLED �Y THE CITY UPON ANV STOPPAGE OF VJOFK ON TFfIS <br />PROJECT OVEH 9J DAYS DURATION. <br />r+ � <br />h� <br />�. <br />cr. - <br />o^ <br />C �. <br />�? _ <br />O� <br />::� ' <br />r; <br />r � <br />� <br />_� : <br />� � <br />