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Date G o `3 <br />Application For <br />PUBLIC VI/ORKS PlERMiT <br />Prini or Type Unly <br />� 1 I �4 <br />S i�"��/I L . <br />Appl;cant <br />Describe Proposed Work <br />Project Address (it known) <br />a'1 L 12. o S" ��-. y�� <br />Mailing <br />City <br />Zip <br />_, ��—(I <br />Public Works PErm�� a�-'7 /� rJ <br />e�ae. oao�.. ��3 " 0 <br />FuefcworksPee r-� _— - . <br />TotalFe¢ $`�J <br />Locs Appl. Foe Pala � � � �� � <br />Balance Due $ — V <br />— 3s5—�� <br />Mailing Address Cit}• Zip Phcne <br />Attach lour (4) copies of plans for oroposed work - Draw lo scale and note the following as applicabie: <br />• Property Lines <br />• Outline and dimensions of ail esisting and <br />proposed sirucWres on Ihe lot <br />s Existing an� proposed utilities <br />c.-- - <br />Ap qv��fp <br />I .� <br />,,.. <br />FINAL INSP <br />�pproved as <br />\ <br />evere[t <br />� <br />PERMIT CONDITIONS <br />• Centerline of street <br />• Indicate North <br />• Show any proposed gradi�g ;hanges <br />! Show measurements <br />t. All calls (or inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be performed in acwrdance wf!h this permit and current City of Everett Design and Consiruction <br />Slandards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />F-7r� <br />ON <br />PUBLIC WORKS DEPAFTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />�w <br />� / <br />O <br />a <br />The undersigned uwner/applicant hereby agrees to hold and save harm- <br />less the Ciry of Everett from any and all claims for damages, costs, <br />espenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further �grees tc remove same upor notice froro fhe <br />Cily and lo replace public proPerry damaged thereby. <br />Jat�a� ///;p ��% � <br />(-G•G�Y�C�W���� � � ��J <br />Signature of Applicant ate <br />WORK AUTHORIZED BY TH'S PEHM!T MUST BE STARTED WITHIN <br />180 DAYS JF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DII.IGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ <br />CANCELLED BYTHE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />il <br />