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N <br />Date I � r � <br />Application For <br />PUBLIC WORKS PEReVI�T <br />Print or Type Only <br />1 r <br />i � � � (-- <br />owner - <br />; _ l���r-��a: <br />i Applicant <br />Describe Proposed Work <br />� ���-/'1 �''� �.Ij.; ;�� . � 1, . <br />,_l„'_, ,_,,.:C_ �,( <br />Mading qddress City <br />—�_ <br />Mailing Address City <br />t' �•� i��, �!. , -- _ . � . -. .-. - , <br />---�R�-?�-' �!��-' <br />PuOLc Woiks Permi� a\ �% '� � 1' <br />Bleg. Depl. r � 1 � � � �,( � . <br />: �i <br />_{T_,� <br />PWLc Works Fce 'i <br />Totai Foe S -_ ; <br />Less Apyl Fee Paid $�- � <br />'_�¢_ M�iJ �� <br />Balance Oue $ .� �_ <br />���� <br />Project Address (it known) _ � � � : � � -�-'-• ' � , , • <br />� L� � <br />�� . � - _�� ;,<' <br />Attnch four (A� copies of plans lor proposed work - Draw to scale ana note the following as applicable: <br />• Property Lines <br />e Outline and dimensions of all existing and • Centerline of street <br />prpposetl slructures on the lot � Indicate Nor�h <br />• Existing and proposed utilities � Show any proposed grading changes <br />• Show measurements <br />��:' ! �i l <br />�Phone <br />� v� rvt�i WHI7E BELOW THIS LINE � <br />� PERMITCONDITIONS <br />i 1. All calls for inspeclion shall be made 24 hrs, in advance- phone 259-$$10. <br />; 2. All work shall be pedormed in accordance with this permit and current Ciry of Everett Design and Consiruction <br />Standa�ds and S�ecifirat�ons. <br />�� 3. Ca!I Locatiori Un,ierground Service 48 hrs. befere you di.,7. TOLL PREE NUMBER 1•$00-424-5555. <br />i 1 <br />y-i /� L� <br />� Y <br />F ✓��/G C,WI/✓1 .� ; . • '� . , . . <br />� _ t; ,. <br />��,�,cc�-7` a o l.< -'f/G' �•.z� � . . . <br />� � �� � ; <br />�F`�"- r'"` . �� � -F' <br />:_ � <br />I.. �. . � <br />� /.''�,.., :' y ;,. �, - . ' <br />_T. ' <br />'� _ __. �^ �_!� � ✓.. <br />' l <br />� A�Praved for CpnsirUc'tion <br />� Date <br />� FINAL ItJSPECTION <br />.; Approved as Constructed <br />' everelt PUBLIC WORKS DEPARTMENT <br />�. � 3200CedarStreet <br />Everett. WA 98201 <br />, Phone.259-8810 <br />Dale <br />_ ., �-- _. `,, <br />� � <br />O <br />� i <br />Y'♦ j <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS � <br />The undersigned ownedapplicanl hereby agrees to hold and save harm� � <br />less (he City o( Everett from any and all claims for damages, costs. <br />expenses, or causes of action ihal may arise because of installalion � <br />and maintenance of ihe improvement or olher rlght-of-way use hereto �� <br />applied lor and further ayrees to remove same upon nolice from the <br />City and to replace public property damaped thereby. � <br />Si�nature ol qpplicant — <br />WOHK AUTHORIZED BY THIS PERMIT MUST BE STARTED WI7HIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TG COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPqGE OF �n/ORK ON THIS <br />PHOJECT OVER 90 DqYS DURATION. <br />