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Date�� Public Worhv Pcrmi�a _ _ <br /> � —7-- <br /> Application For BItl9.0ept.n�_�_I_��_�_..�_____ <br /> PUBLIC WORKS PERMIT PubTolalFceF^e S_ <br /> Less Aop�.fee F3ie 5 <br /> Print or Type Only e��,�«o�e s ^ <br /> �-�•-��� ���� ��5 (1J� ��=� ��'-r�- ��� r�� � �r=�2c=�1— �R�>v'�� ����2—��l�C� <br /> wner Mailiny Address City -T—Zip Phone <br /> ����r��r �-�� ��;>_ fi�!(�1-�l�a�.�r� �1�� �-=���-b�- �i��zni 2�-��l�r� <br /> Applicant Mailing Address Ciry Zip Phone <br /> Describe Proposed Work � I�.�r����_ f1(_r <br /> Project Address(if known) ,'/l�Jl�� I r�l� � <br /> — � <br /> Atlach four(4�copies of plans for proposed work- Draw to scale and note ihe tollowing as applicable: �� <br /> • Property Lines • Centeriine of sireet ♦� <br /> • Outline and dimensions of all exisling and • Indicate Norih �� <br /> proposed structures on the bt • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measuremenls � <br /> DO NOT WRITE BELOW THIS LINE <br /> PER�dIT CONDITIONS � <br /> t. All calls for inspection shall be made 24 hrs. in advance- phone 259-881 5. � <br /> 2. All work shall be pertormed in accordance with this permit anG current Ciry uf Eve�ett Desi�n and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Servic�. Af� hr;. belore you dig. TOLL FREE NUMBER 1•800-424•5555. � <br /> �I'� ' ( �_�� �_C �� /j/ `yI/ � <br /> �,_ 1— f,�_ i� � <br /> ���;,. -� 0".. <br /> � <br /> � <br /> � <br /> ACt<NOWLEDGE�viLNT OF CONDITIONS <br /> Thc undersgned owner/applicant hereby agrees to hold and s2ve harm- <br /> - Iess Ihe City of Everel! from any and all claims for damage;. costs. <br /> expenses, or causes ot action that may arise because of insL:�lation <br /> and maintenance of the improvement or other right-of-v�ay use hereto <br /> - �,pplied for and furiher a9rees to remove same upon notir,e irom the <br /> Approv^_d for Construc�fon D:i�e Cd9 nnd lo iepl;iCc public pioperty damaged therel�y_ <br /> FINAL INSPECTION Date __ ._._ <br /> Approved as Conslructed S9n:du�o of Applic.�nt Date <br /> evereu PUBLIC WORKS DEPARTMENT WORK AUTHOHIZED �'f TFIIS PERMIT MUST BE STARTED WITHIfJ <br /> � 3200 Cedar Street 180 DAYS OF UATE PERMIT IS ISSUED AND TIICREAFTER IS TO <br /> Everett, WA 98201 BE DIUGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 6[ <br /> Phone�, 259�6F31 i CANCELL[� BY THE GTY UPON ANY 570PPAGE OF WORI(ON THIS <br /> PROJLCT OVER 00 UAYS DURAiION. <br />