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Date �—��i$ <br />Application For <br />PU�LIC VI�ORFCS PEi�MIT <br />Print or Type Only <br />Applicant <br />i <br />I '�� <br />Address <br />Mailing qdtlresa <br />_ i ,':' <br />City <br />Ctly <br />Zip <br />2ip <br />i <br />�$- 33T�—� <br />a��ei�: wmk:: rvmn n („—, — 1 <br />eiea o��i , <br />��„�,�Wo,�=F�� S <br />�olal Fcc <br />Less AppL Fee Paia S ��— <br />Eialance Oue $ <br />Describe Proposed Work ya—���, � 1 � � �.�' ���C ��� ���� <br />Project qddress (if known) <br />_ %'`�' ,L�.C', �: <br />Allach four (4) copies ol plans tor proposed vorF; - Drav+ tc �cale and nofe �he (ollowing as applicab�e: <br />• Properly Lnes • Centerline of sireet <br />• Ou!line and dimensions of �II exis!ing and Y Indicate Nor�h <br />propused structures on the lot • Show any proposed yra<>��., changes <br />• Existing and proposed utilities • Show measurements <br />BEIOW THIS L <br />Phone <br />PERMIT CCNDITIONS <br />1. All calls :ur inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All wuik shall be performed in accordance with this pe: mit and current City o( Everett Dasign and Construction <br />Standards and Specificaf�cns. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />, tli`dY �;HANGir Ihl 1�� li� DFi:[ V1=ldrl`( CIJT hILJS'i E:tF AFF'1='Ot'cl) <br />bl' TI�E F'U:=1_T.0 tJOkt:� ri,I�PECI��F'. <br />?.U�iE PUBI..IC DF�AIIUAGE SYSTFI7 (1 i F'ROVIDED FOFi DO�,1P1'ii}'lll.!"(.`.�. <br />_•. r1NY LOT GRAD� CHANf3E5 MLI�T BE i�FFF±QVED PY "I I IP, <br />F'UPL_SC 1J01iKfi 7NSF•E:i;l'QI;. <br />'•�:EEF' Cl:fl' �'fhEETS CLEAN A"i ALL I'IhIE�'. <br /><:. :[NSTAI_L W� I ES EtpXES TD LFADF (1T 1 HE EPJD <br />`%.MAI`:E 3URE llRIVEbIAYE, (1FiE COI'1F'LGTELY GURED <br />UFt i V I MG ON ThIEt1. <br />OF C;OhiSlFiUl�r:[Oh: <br />E+EFOFiE <br />'-�•./i�:ll' D(1Mf1GE f0 THE CUF9=; FlI�ID SIDEI�J(1L1:: l�l1LL. HE RF;='riIRE:i) <br />i l "l t'F :,/dl "i SF �f' i:l':lpl i1F= 1'I �. !'! I�-:I 1 f i li�;"(I: ' L/4'F" I. <br />��r��.___._ _ -_-_-- <br />�K 91f/���oa�� 8 /�9-n�8 <br />Approve�� Corr,t ru tion , „ pa�e <br />i / � i <br />`: . �' {��/� , : �./1� <br />FI A' NSPECTION� � ' Date <br />Approved as Constructed <br />eaerelt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />EveretL WA 98201 <br />Phana 259��3310 � <br />ACY,NOWLEDGEMENT OF CJNDITIONS <br />The undcrsianed owner/apPlican� hereby agiees to hold and save ha�m� <br />Iess Ihc City of Evere�l from any and all daims for Oamages. costs, <br />expenses. or causes c� action ihat may arise because ol inslallation <br />and maintenance of ihe irnprovement or olher right-obwaY use hereto <br />applied for and lur�her ayrees to remove same upon notice from �he <br />Ciry and :o replace public properry dama9ed Ihereby. <br />, <br />;_. : �%;� , - � �� � � <br />Signature of J.pPlir,ant Date <br />WORK AUTIIORIZGD BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE P[PMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PEHMIT MAY BE <br />CANCFLLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATIOIJ. <br />