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Dat/�G�.$— <br />Application For <br />Pl16Ll� WOR�S FER��IT <br />Print or Type Oniy <br />Address <br />Ciry <br />a�eu�wo�xsa��m�n+ _ <br />BItlB� Dept. a _ <br />Publit Works Feo � <br />Toial Feo � —��'� — <br />Less M1ppl Fea Pni� S_�_ <br />Baiance �ue $ �v <br />51�:1R� �5 1'—lf3uVL� <br />Applicant Mailing AddresS City Lip Phone <br />Describe Proposed Work C-� N'S��'UC } S I�N GLQ Rl�YY1LL�/ _(ZPSbi7�C.P <br />G o7 I1� �i7- �/ic� �d <br />Project Address (if known) <br />Attach four (4) copies of plans for pr000seA work - Draw to scale and note the iollowing as applicaGle: <br />• Property Lines <br />• Outfne and dimensionc of all existing and <br />proposed sirucWres on the bt <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />• Cenfeiline of sireel <br />• Indicate Norih <br />• Show any proposed grahing changes <br />• Show measuremenis <br />LI <br />1. All calls for insp2clion shall be made 24 hrs. in advance - phone 259-8815. <br />2 AI! work shall be performed in accordance with this permit and current Ciry c��l Everett Desi9n and Construction <br />Standards and Specitications. <br />3. C`�I Locetion Underground Service 48 hrs. befora you dig I'OLL FHEe NUM6ER 1•800•424-5555. <br />� <br />��r'�'I ' 7 Z -�n <br />FINAL INSPECTION y Date <br />Approved as Consiructed <br />everet[ PUBLIO WORKS DEPHRTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-881 5 <br />h'° 9.'9 <br />ACKNOWLEDGEMENT OF GONDITIONS <br />�1 <br />� <br />� <br />� <br />O <br />a <br />The undersigned ovmer/2pplicant hereby agrees to hold and save harm- <br />less ihe City ot Everett fron any and all claims for dam2ges, costs, <br />expenses, or causes ol ac�ion that may arise hecause of installation <br />and maintenance of the improvemen� or cther ri�ht-of-way use hereto <br />applied foi and furtl��°r agrees to remove same upon notice from the <br />City and ,o replace public prope k amaged ihereby. <br />---/�� "—' '�b_v_�-.� � � �G ' �S <br />Signalure of Applicant Da�e <br />WORK AUTHORIZE� 8Y THIS FERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE F�RMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY f'LIRSUE� TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BYTNE CITY UPO�' ANYSTOPPAGE OF WORK ON THIS <br />PROJECT OVER 30 DA1B �URATION. <br />