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, _ . . � _ ._____ <br /> � <br /> � <br /> I <br /> � <br />; I <br /> � I <br /> Date���� r„�,�,�tivo�.�v,.,�„„ c��'� <br /> Applicalion For n � ��°� �`P� , — � <br /> PUBLIC WORKS PE�iMIT � `���'r;,;;F��F�� s ��=� � <br /> m <br /> � lass Appi Fee Poia S <br /> �= r� <br /> c � (y <br /> �l p :� O Palancc Uuc $ �/ '� <br /> Print or Type Only = ca c, o o - <br /> �`' c-i o o- o� <br /> � o v� c- c�d <br /> ,� ;n c',� .r �� <br /> �„�:��c��'i �o�s �f. �o. �T.-�c- �� ��.�'S'/S�� St- E����/� w� %6'Zo/ 339�3/c; ��I <br /> Owner Mading AAdress •� � � � � i�iLy, Zip Phone �'� <br /> � o . ti <br /> O pF— I— H W <br /> \ u} O f 2 <br /> 5�.,-,� �p'6� �t,-r��`✓' r<c�i�,q /?��dc,ci;J <br /> Applicant Mailing Address City Zin Phone ' <br /> Describe Proposed Work `�<<C� /7Cl.�/ rfG.�i�7 o�✓ct�hc, qC�_" �`'�» c�.-,;� �'�� <br /> '1- �i� n, E �/-� '� S� - <br /> CJ OC,d '3 <br /> .��/5 /.s` ST � <br /> ProlPct Address(il known) G .4 , p �C��, )1�� �L� ��i � <br /> Attach four 14)copies of plans lor proposed work� Draw to scaie antl note the following as applicable�. � <br /> • Propr,rty Lines • Certerline of sireet � <br /> O Outline and dimensions ol all existing and • Indicate Norih <br /> proqosetl strcctures on ihe lot • Show any proposed grading changes <br /> • Existing and proposed u�ilities O Show measuremenis � <br /> DO NOT WRITL BELOW THIS LINE � <br /> PERMIT CONDITIONS <br /> 1.All calls for inspedion shall be made 24 hrs.in ad��ance-phone 259-8Li10. � <br /> 2.All work shall be performed in ar,cordance with this permit and current City of Everett Design and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> �/ / / ,/ '� /� <br /> �7� �-Y G-/,�j:,�-atrr'cL /�,�r s- �rv,G-�SE/,�7 E'i'`� � � <br /> / <br /> � <br /> Y/ <br /> i �� `�/`�/ � � <br /> l��1/ / / / � � <br /> (, / /��,/� <br /> � v <br /> / <br /> � ACKNOWLEDGEMENT OF GONDITIONS <br />� � The undersigned owner/apP�iCant hereby agrees�o hold and;ave hainr <br />', less ihe Ci�y ol Everett Irom any and all claims for damayea cosls. <br /> "�- � expenses, or causes of action that may arise because of installation <br /> �—� <br /> --r��'`� � � /�/�G and maintenance ol the improvemen� or other righbol�way use herelo <br /> =��'''�` " �•—;� � � applied lor and Iwiher aqrees to remove same upon nolice from �he <br /> A prpVed tor Co tuclqn � :' Date City and to replace pubBc properry damaged thereby. <br /> !�����/ ��,��_�., - <br />. FINAL INSFECTION Date �G����� ��:���� �'n�- C ���`' ; <br /> Approved as Construcled �SignaWre of Applicant " ' Date <br /> everett PUBUC WORKSDEPART�dENT WORK AUTHORIZGD BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarStren� 180 DAYS OF DATE PEAMIT IS ISSUE� AND THEREAFTER IS TO <br /> Everetl,YVA9A201 BE DIUGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 6[ <br /> Phone:259�8810 CANCELLED BY THE CITY UPON ANY STOPPAGF OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />� <br />