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_ 3 �� 9e - <br />Date 3 i h'8 � <br />Application For <br />�'UBLI� WOR�:S PERMIT <br />Print or Type Only <br />m <br />Applicant <br />Address <br />Mailing Address <br />� <br />City <br />City <br />Pwilir, Works Permil s �� _ `� / <br />31tly. neD�. ^ _ <br />PubL[ WarFs Feo d / (] ��a <br />Tolal Fce s � � <br />Lrss AOPI Fen Ga�tl CJ . <br />�U no <br />c�,��,�„�� o�� s _ <br />� �!'J J — GC�LJ <br />Z p Phone <br />Phone <br />Describe Proposed Work /V�� S. %�� . LOT �t O� y,p_c�� / f�,qi2�-� <br />P�oject Address �if known) �0/ 2 G' —/�/�/Q s.�_ _ <br />Attach lour (4) copies of plans for proposed work - Draw io scale and nole ihe following as 3pplicable: <br />• Property Lines • Cented-ne ot e.treet <br />• Outline and dimensions of all existing and • Indicate Norih <br />proposed structures on the lot • Show �,ny proposed y7rading changes <br />• Exis�ing and pwposed utili':,=. o Show measurements <br />WRITE 2EL <br />PERMIT CONDITIONfi> <br />1. All calls (or inspection�sheli 6e �nade�24�hrs. in adva�ce.: phone 259•8810. <br />2. All work shall 7e performed in accordance with this permit and current City of E:�relt Design and Construction <br />Standards and Specifications. <br />3. Call Location Ur�erground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424-5555. <br />:,. Fd`dY CI1AlVGE :lV l Hl= 6F'I VEW(-lY CUT I`11J5'1' E:E APF'F'pVED <br />i�Y TI;E F'IJT;LL.IJUEif:S-I.N�PEC"ffJR. , ._.. ._ . ._ . <br />S.!.J:�F FUPLIL' DF:AINAGF_ S`rs-rcih A6 F'F•:OVIDFCi FQF: DOWP�61''O(..;T:; <br />�,.�qIVY I_OT GF�AUE CHANrI_, MUST. HE AFFRO�!lL=.0 E+Y TIiE ._ <br />F'UL-�LIC WOF'k:S II�ISF'CCTOF, <br />7.1':I=EF' C1:'1"Y STREETS CLEAN AT AI_L "I'II`1Eo� <br />=., UVFS"fALL. WAl'ER L:nYES l'Q 13FAC�E f-.T 'f!-!E: EI�.ID C'F r��IN�'fl='UCTiC1Pl <br />':%,C91'�':E SUI;E D{-'t�.�' I��-.•,'S �' i ��f�11�1 I_ii:iL4 �.UP:EC. � f I(]i'.I <br />D�; I t.'I"!(_ Cii I TI I[_PI, <br />:lpproved lor Co <br />FIfJAL INSPECTION <br />Aopioved a= Constructed <br />evcrel[ PUBLIC WORKS DEPPRTMENT <br />� 3200 Cedar Street <br />[veretL WA 98201 <br />Phone�.259-6810 <br />/� � p <br />Datc <br />/�/��7 <br />Date <br />ACKNOWLEDGEMENT OF CONDITIONS <br />/ <br />The und,..,igncd owneNapplicanl hereby agrees to hold and savc hanm <br />less the City ol Everett irom any and all claims tor damaces. cosis. <br />exper.ses, or causes ol action that may arice because of installation <br />and mahden.u�ce nf the improvement or other righbof-way csP hereto <br />applied lor and fwiher agrees lo removc same upon no�ice Ircm �k�a <br />Cily and lo replace , ublic property d:.imaged iheieby. <br />-�',���i ��.1�-�LYI'� /���v / �� <br />Signa�ure ot Applicant Date <br />WORK AUTHORIZ[D BY THIS PERMIT MUST BE STARTED WITHIN <br />7R0 DAYS OF DATF PERIv11T IS ISSUED l��D THEREAFTFp IS T� <br />BF DILIGf_'2TLY PURSUED TO COMPLETICN. THIS PERMIT MAY �r <br />GANCELLED B`f THE CITY UPON ANY STC"FAGE OF WORK ON THIS <br />PROJECT OVGR 90 DAYS DURATION. <br />