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Date��s <br />Application for <br />I�UBLIC Wd►RKS ►��€�iVll'T <br />Print or Type Only <br />Owner <br />Describe Proposed Work <br />�'�Z?.� 3\l? <br />Mailing Addrass <br />Idailing Addre�s <br />City <br />City <br />Zip <br />z�� <br />Public Works F^��m/it ♦ `� ��� 37/ <br />Bi�]a.0ept. r .8_� i�J.,� <br />--7 <br />Piip;ic Wmhs Fee � — — <br />latalFua ---- <br />Less ApO�� �ee Paic $ -- <br />-� �XJ <br />�alance Dua $ — �� — <br />ProjectAddress(ifknown) �r��-7��� ��-]�7— �th���__ <br />Adach to�r (4) copies ot plans for proposed work - Draw to scale antl note the followiny as applica�ole: <br />e Properry Lines <br />• Outline and diinensions of all existing a�d <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PERMIT COND:TIONS <br />• Centerl;ne o( streel <br />• I: dicale Norih <br />• Show any proposed 9radin� ohznges <br />i E��how measuremenis <br />ne <br />Piione <br />1. All ealis toi inspection shall be made 24 hrs. in advance - phone 259•881 S. <br />2. All work shall be performed in accordance with this pe�mi[ and curcent Cily of Everett D�:;;�n and Construc': ���, <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•F06-424•5555. <br />/-f /l�[Jy ��/_'Avi.r/cL %JLU'.!E OiC! l%/E L.O T...�NGGG i.: c' <br />/ <br />/,�ONE� SO LJS NOT jc� Zi7/�,4G7 Jj,if SG;t�c'CUti���/✓Lr- <br />�OTS I•�iT/� /ndi'J LLiljTf.E' <br />/ /�-�'../% ~ �?�✓I� �2/�7 <br />Approved tor Cons ruction � ate <br />s �5l ��v <br />FWAL INSPECTION �� Date <br />Approved as Consiructed <br />everett PUBLIC WONF�:; DEPARTMENT <br />� 3200 Cedar Strer.l <br />everetl, WA 98201 <br />Phone: 259-881 � <br />� <br />L J <br />� <br />/, c r'✓-O�' � <br />� <br />� � <br />ACKNOWLEDGEMENT OF CONGITIONS <br />The undersiyned owner/applicaN hereby ac�rees to hold and save harm- <br />les� the City of Everett from �ny �nd ail claims for damages, costs, <br />expenses, or causes of action that may arise because ol installation <br />and maintenance o e improvement or o�her riaht�obway �se ,�.areto <br />a lied 1or and1��ur he agrees to remove same �pon notice trom the <br />ity d to rep;al�i 6 property damaged thereby. <br />� � � �z�� �� <br />Signature ol Applirant Date <br />WCRK AUTHGRIZED BY THIS PERMIT MUST BE $TART"tD WITHIN <br />180 UAYS OF DATE PERMIT IS ISSUED AMD THEREAFTER IS TO <br />BF. �ILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK. ON THIS <br />PROJECT OVER 90 DA'�S DURATION. <br />