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Date �_�iC� <br />Application For <br />PNBLIC lNORKS� PERN9lY <br />Print or Type Only <br />� ( 'l <br />ANPlicant <br />Mailing <br />Mailing Address <br />Ci�Y Zip <br />P�b,u Works'ermi� v "-' /�J� / <br />,,�,��P�, go/z3g�19 -- <br />v�:�ec Works Fnc <br />Ta�ol Fee 5 <br />�rss Appl Fee Pnitl S ^'� <br />(3alance Dve $ "��J � <br />Phone <br />Describe Proposed Work ��� � LOT 1Ce � ���AV� ����,�.{,.�� <br />Prciect Address (if know��) ���7 ^ �T}� <br />Attar.h tour (4) copies of plans for proposed work - Draw �o scale and note ihe follow�vg as applicable: <br />O Property Lines • Cen�erline of street <br />• Outline and dimensions of all existing and • Indicale �orth <br />proposed siructcres on ihe lot • Sho�v any proposed grading chanyee: <br />• Existing and oroposed utilities • Show measu�emen�s <br />PERMIT CONDITICNS <br />1. All calls (or inspection ;hall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be performed in accordance with this permit and curreN City of Everett Desiy.� and Construction <br />Standards and Specifications. <br />3. Call Location Undergrouno Servica 48 hrs. before you dig. TOLL FREE NUMBER 1-800•42•1-5555. <br />^.�tdY �HraNG�= IN TI-IF_ ;'IVEI�IAY CUT Y1USl' HF_ APFF'ny�'f: <br />RY TIiF PUBLIr WpRI JNSF'ECTU';. <br />_ ,,,:;ONNECT UOWNSF'OUTS FIJELIC DRAIf�II-1GE SY5TEM. <br />': , P:FFF C.T.'fY 5TRF''fS 'lIV (�"f ALL TIMFS. <br />', Ahll' D(ll^Af�F Tll 1' �" �. so Al�ln cIGEb1Al_I': I�III..L 2F !2EI'f'i i RFI) <br />TO l l-IF S;FI f)' �1=AC i T[:I�, 'hT T: I; . I''l 11:tL.7 i; l�l("!;-r�;_� n;-'-' ;' , <br />� ' ' 1 `, v` ? 1 � � <br />Approved (or Consiruc�ion/ Dale <br />/ l ,!i <br />���� /O-// � �. <br />FINAL IPC P,ECTION Date <br />Approved as Consiructed <br />everetl PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone:259�88i0 <br />ACKtJ7WLEDGEMENT OF CONDITIONS <br />The undersin^.�d owner/appllcant her�by agreas to I��oltl and save hann- <br />less tlie C:ly ol £veiett Irom any and all claims ior damac�es, cos�;.. <br />eapenses, or caus;• >( action that may arise because ol installation <br />and rnaintenance ol .�e improvemen� or other righ;�of-way use, hereto <br />applied lor and further agrees to remove same upon rotice Irom the <br />City nd, o rep acepp blic proper damagetl thereby. <br />. ��1� ;H�`����� �ir,� <br />� � <br />Signa re of App ican�� Date <br />WOFK AUTHORIZED BY THIS PERMIT MUST ElE STAliTEG WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY Pl!RSUED TO COMPLETION. THIS PERMIT MAY B[ <br />CANCELLED BY TFI;: CITY UPON ANY STOPPF?E OF WOHK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />