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1 1-" I <br /> p$�Q �� i � �' � Pu�LC Vlo�hs Pa�mi�a <br /> ApPlication For Blag.�epl.+' �, / '� �� L <br /> PUBLIC WORKS PERMIT °°^��°�Y°�k=F« <br /> To���F�� s <br /> �ess npni Foc aa��a S <br /> Print or Type Only o��,���o�� s <br /> �-��/� 1� . /i` � �`� �. � ��x��,. �.� C'�� ��. � i��:� � :�- 1 .. 1 �-'�" �� � �:��f�'�-: --�� _� �_ (-C{��,� <br /> Owner Mailiny Address City Zip Phone <br /> �� �l�-�� � ��.— <br /> � Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work -� p C/-�� <br /> �- .�. ,_ t� : � ; W <br /> Projecl Address(if known� � ��� � � � � ����- � � <br /> Attach four(41 copies of plans tor proposed work- Draw to scale and note the follov�ing as applicable: � <br /> • Property Lines • Cen�erline of street ♦A <br /> • Outline and dimensions of all existing and • Indicate North �� <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed u�ilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS � <br /> 1. All calls for inspection shall be made 24 hrs. in advance- phone 259•881 5. � <br /> 2. All work shall be performed in accordance with this permil ar,d current City of Everetl Design and Construction <br /> Slandards and Specilications. <br /> 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> �l/�G/C l�-Ja/��S' f���rn�T �,/oT �E'�G��2�D � <br /> �� � <br /> �-�-�� � <br /> a <br /> ACKNOWLEDGEMENTOFCONDITIONS ��, <br /> The undersigned owner/applicant hereby agrees to hold and save harm- �I <br /> less Ihe City of Everett from any and all claims lor damages, costs, <br /> expenses. or causes of action that may arise because of installat:on I <br /> and maintenance of �he improvement or o�her righbobway use herr.to � <br /> applied for and furlher agrees to remove same upon notice from the <br /> Approved for Consiruc�ion Date City and tu repiace public property damaged thereby. <br /> FINAL INSPECTION Da�e <br /> Approved as Constructed SignaWre ot Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WOHK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarStreet 18G DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MHY BE <br /> Phone: 259-8815 CANCELLED BY THE CITY UPON ANY STVPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />