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Date_7/��� "�] <br /> Public Works Permi�a <br /> Application For Bltlg.Dep1.a <br /> PUBLIC �iVORKS PERMIT � P�b���Wo�ksFoa <br /> Toial Foe S <br /> �('� <br /> Less AppL Fee Pa�id 5� <br /> Print or Type Only BalanceDua S �Zl� _ <br /> �� � � % �3P �c s �{ pt. 6zz -zE� z6 <br /> O�vner MailingAddress Ci�y Zip Phone <br /> S �1 �YI� � �U I� PUFII�� �''IFnJf r'?P �IPd4f' ��007 � �Z -ZC�, Z ( <br /> � <br /> Applican� Mailing Address City Zip Phone <br /> Describe Proposed Work C lP C� �' `� / ��`�^ �� s � / P <br /> � C��� r�C:�S C Lt !� �F / �� — <br /> � ��3� /�r�S s i (j� <br /> Proiect Address(it known) � L ��//�J/`�!� _�- ,�s., � <br /> Attach four(4) copies of plans for proposed work- Draw lo scale and note the tollowing as applica.te: �� <br /> • Properry Lines • Centerline of street /w <br /> • Ou�line and dimensions of all existing and • Indicate Norih V, <br /> proposed struclures on the lot O Show any proposed gr2dinq changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calis(or inspection shall be made 24 hrs. in advance- phone 259•881 5. � <br /> 2. All work�hall be perlormed in acwrdance with this permit and current Ci�y of Everell Design and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underc�round Service 48 hrs. belore vo�dig.TOLL FREE NUMBL-R 1•800•424-5555. � <br /> �., C�'P.Q r//1�/ l-t��cL���a�� oy/C` � <br /> � / <br /> � � �h''d5/O I'L C�OY(7/�lJ ( �' C� TI �c� �� C li�cl�/� � <br /> �� � �n��r <br /> V/ <br /> O^ <br /> 6i <br /> ACK�OWL[DGEMENT OF CONDITIONS <br /> ?he undersigned owner/applicant hereby agrees to hold and save harm- <br /> / less the City of Everett �rom any and all claims for damages, cosis, <br /> expPnses, or causes of action that may aris� because ol installation <br /> 7 �— ��— and maintenance ot the improvement or olher righbof-way use hereto <br />�� Ap�prov lor onstru��2--- — aPPlied for and further agrees to remove same uPon notica Irom the <br /> Date City and �o replace public properiy damaged thereby. <br /> � � G s-- 2 � _�� !�-,_�:�L�' �l. �� �� <br /> FINA� INSPECTION Date L� <br /> Approved as ConsVucted Signature of Applicant � Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT'MUST BE STARTED WITHIN <br /> � 3200 Cedar Street 780 DA'i 5 OF DATE PERMIT IS ISSUED AND THERE�FTER IS TO <br /> Everelt,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone: 259�8815 CANCELLFD BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />