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Date 9-� � -P% <br />Application For <br />PUBLIC V✓ORKS �PERMi�' <br />Print or Type Only <br />)')'iF I�a,�, ;t-��v,, t�� <br />Owner <br />S�/.�.e. <br />Applican� <br />iling Address <br />Mailing Address <br />� <br />C�13 <br />Publlc WorkS Permi��.r— �� <br />�Idq. Dept. t _., �J _� <br />PublcWoiksFec S <br />lolal Fee <br />Less ApPL Fee Paitl 5 <br />oa�anco ouo S �� <br />i <br />DeScribeProposedWork (/lP[.t/ .P�L� �(� ��i .L`r�rJ�vr ���%( U <br />/N <br />Project Address (if known) <br />Atlach (our (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines . • Centerline ot sireet <br />• O��'�ne and dimensions of a!I existing and • Indica�e North <br />proposad slructures or ihe lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />Phone <br />Phone <br />FERMIT CONDITIONS <br />1. All calls tor inspection shall be made 24 hrs. in advance - phone 259-8815. <br />2. All work shall be performed in acwrdance with this permit and current City of Everett Desi9n and Construction <br />Standards and Specificaticns. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424•5555. <br />. . , .., .,. .. ,, i�� . <br />_: PUE�!..iC DSAtP•Ii1GC-= '_Y�ii=1°I �aS r-�Fr�,rnEf? FqR � <br />` LQ'� (;Fir1TiE CI-Ir114UF.S <br />c�t_TG t�1nRK5 ;.�a�:r�r_.rc�r <br />;F' CIl"Y STREET� Cl...'L� <br />J'I-Al. L WR i;=F L:��:k F'_; 7u _ <br />,r _. ,�� �, <br />Approved as ConsVucted <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedai Sire=_t <br />Everc�t, WA 98201 <br />Phonc 259-861!i <br />ACfWOWLEDGEMENT OF CONDI"IONS <br />I <br />i <br />W <br />� <br />se <br />� <br />The undcrsi��ned owner/applicanl hereby a. rees b hold and save harm- <br />less the City o� Everett Irom any and all�ciaims for damages, costs, <br />expenses, or •��uses of action ihat may arise because of installation <br />and maintenance of the improvement or ��inar right�ol-way use hereto <br />appiied for and further agrees to remove same upon notice from the <br />City �rd to replace public property damaged �heieby. <br />� iG <br />� ' �. - %.�:�i��?� ��G�J� <br />Si�nalure of Applicant � Dalc <br />WORK AUTHORIZF� BY THIS PERRIIT MUST BE STARTED WITHIN <br />180 DAYS OF Di,TE PERMIT IS ISSUED AND THEREAFTEP IS TO <br />8E D'�LIGENTLY PURSUED TO COMPLETION. THIS PEAMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 40 DAYS DUHATION. <br />