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Date � �l "g 7 <br />ApPlicaticn For <br />F'UBLIC V►f�RKS PERIVIIT <br />Print orType Only <br />Apolicant <br />Describe ProposPd Work <br />ng Address <br />Mailing Address <br />Project Address (if known) J���� <br />Attach four (4) copies oi plans for proposed work - Dravi to scal� antl note the following as applicable: <br />• Property Lines <br />O Oulline and dimensions o( all exis�ing and <br />propnsed structures on the lot <br />• Exis�ing and proposed utilities <br />Pebl¢ Works Permi� � �l� �0-- <br />eiep. Dapt * _I �� <br />Puelic works Fee � <br />Tolnl Fee <br />Less ApO�� Fec Paid 5 <br />Balence D�e $ 2�% �O <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />ne <br />Phone <br />PERMIT CONDITIGNS <br />t. All calis (or inspectien shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work. shall 6e performed in accordance with this permit and cuvent City of Everelt Uesign and Consiruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TO:.L FREE NUIVIBER 1-800•42d-5555. <br />� if'un� ,F'o�F-Tor� J>�wNsPouTs /,rJ,-v j,e'/rtiEGG S <br />5 S�vEc�c�� Cv.eB �' Gar,-E,e A,eE �.rNl32o,�E'•✓� A,dy <br />l��MF,�GE� �PESC//.Ti�G �On'Jr !i'J,C',�� SH9Gc 8E <br />��E�L9GE0 �y T�/� APPGC9a/T, Ty�s <br />�r, G�.SE Fxisri.✓Cs G,G�inEi<J9y <br />Approved for <br />FINAL INSPFGTION I \ � <br />Approved as C�nsiructed v <br />everett PUBLIC WORKS DEPARTMENT <br />_ � 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259�8875 <br />0� <br />Da�e <br />ACKNOWLEDGEMENT OF CUNDITIONS <br />� <br />Y/ <br />0 <br />a <br />Tne undersigneo ownedapplicant hereby a9rees to hold and save harm- <br />less the Ciry ot Everetl from any and all claims for damages, costs. <br />expenses, or causes of action that may arise because of ins�allation <br />and maintenance of the improvement or other nghPol-way use hereto <br />applied for and lurther ayrees to remove same upon notice from ihe <br />City and to replace pu5lic property damaged thereby. <br />!!' G-�^- '/ / �CJ.�.�l '1 � � � �L— <br />Signature of Appli an <br />° Da�e <br />WORK AUTHOR�ZED BY THIS PERMIT 1�4UST BE STARTED WITHIN <br />160 UAYS OF DATE PERMIT 'S ISSUED AND THERF.AFTER IS TO <br />BE DILIGFNTLY PURSUED TO .^,OMPLETION. THIS PERM!T PAAY 8E <br />C/�NCELLED BY THE CITY UPON ANY STOPPAGF OF WORK ON THIS <br />PHOJECT OVER 90 DAYS DI�Rl�TION <br />