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oace���'4 <br />Application for <br />Pl�BL1C WORICS �ERIViI�` <br />Print or Type Only <br />Public 1'rorks Permi(l �a�- ��"� _ �" � <br />Bir,9 oect r /3 � � %r� � <br />Publi� Works Fee <br />Tole��ea S — <br />Less ApPI. Fea Pnid W <br />�alanceDu �_r� <br />1�-�li �tT �;���% <br />P ione <br />?hone <br />!' G��L,� / % � <br />Describe Proposed Work -�/�!C� � / /7! �?� C ���-C�J������� _. _ <br />� <br />ProjectAddresslilb;nown; _ ��-��� 9'�� �'�� `S-. <br />Fitach lour 14� copie��. �f plans for propoeed work - Draa� to scale and note the following as applicable: <br />• Properl r Lines <br />d Oulhne and dimension= of all existing and <br />;�oposed siructures on the lot <br />• Exi:ting and proposed ��lilitics <br />PE�`41T CONDITIONS <br />• Genterline ef street <br />• Indicate North <br />• Show any proposed grading chenge�:: <br />• Show measurements <br />t. Hil cails (or inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in accordance with ihis permil and current City of Everett Design and Constructior. <br />Standaids and Spec'�ications. <br />3. Call Location Underground Service 48 hrs. before yoa dig. TOLL FREE NUMEER 1•800•424•5555. <br />r, %/C-�fT- li.f/c= �C o� ;-`r Tc,, ^' ��p: t�y �'; �. ,-s Tc-� <br />C��:�,/�_'�:[ i <br />�-7` �i / J Jt:if'"-i-_. /i� lf <br />i-C�.sL- �7 E <br />A�proved for Co�siructior. . Date <br />G l �� Q r, <br />_��� .� D � � A � <br />FINAL JSPECTIGN Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />EverelL WA 98201 <br />Phone: 259-Ef1? + <br />ACKNOWLEDGEMENT OF GOfJDITIONS <br />W <br />� <br />♦ <br />Z� <br />� I <br />The �.indessigned owner/applicant herebq agrees lo hold and save harm- 'i <br />less ihe City of Everelt from any and all claims for damages, costs, I <br />expenses, or causes of .ction that m�; arise because of installation �I <br />and maip tCnance of th� i provernent or other righl-obway u;e herelo � <br />applied �or nd fur�hei � 9rees to remove same upon notice irom the �, <br />City and to �Place p� ic property damzged thereby. �., <br />Signature ol p�liC2hM' " " `�` - D21e ' <br />WORI< AUT RIZED BY THIS PERMIT MUST BE STARTED WITIiIN <br />780 DAYS DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />3E DILIGEN LY PURSUED TO COMPLETION. THIS PERMI? i�4AY BE <br />CANCELLED BY THE GTV UPON ANY STOPPAGE OF WORK ON THIS <br />PNOJECT OVER 90 CAYS DURATION. <br />