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I <br /> Date �•:�;�,����a,�..r,.,�n,� 7 ���/�Z? <br /> f31tly.Depi.+ <br /> Application For � � <br /> Pl1BLIC WORKS PERNlIT A°°°�Wo�k=F�� — <br /> To�al Fce 5 <br /> C�. Less Appl.Fee Paia S _.,/_Q�_ <br /> �� r�� <br /> Print or Type Oniy � 26U � o�����oo�� s �J� <br /> J <br /> �n/1�v�rr Co�vs �T Co. .l.v�_ 2�G ni Sfttc ,B�//i„ h•..., �,./r 98zz� � <br /> Owner MailingAd ress Ci�y Zip hone �Z33_Za6� i <br /> 'i .Si9/�JF /�S /}.J�vF <br /> Applicant Mailing Address Ciry Zip Phone <br /> Describe Proposed Work !7 fjT�/� �L/:�N% <br /> Project Address(if known) �.3/� — /S� � Sf .E��✓e'� wl9 9C+"2o / w <br /> � <br /> Atlach four(4) copies ol plans lor proposed work- Draw to scale and note the(olloviing as applicable: � <br /> • Properry Lines • Centerline of street /� <br /> • Outline and dimensions of all existiny and • Indicate North ��� <br /> proposed slructures on ihe lot • She�.v any proposed grading changes I <br /> • Existing and proposed utilities • Show measurements � � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS � <br /> t. All calls(or inspection shall be made 24 hrs. in advance- phone 259-881 5. � <br /> 2. All work shall be performed in accordance with this permit and current City of Evereq Desi�n and Consiruction <br /> Standards and P,pecifications. <br /> 3. Call Location Underground Service 48 hrs. be(ore you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> � / ! /� (�e <br /> "� �'/2�✓ C%„�� `:'t��'��p/ ,�_/J.'C-fL1 ,/� !r7�'�✓� `"1 - .:�/ ���j \ <br /> � <br /> � I <br /> � I <br /> � <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned o�vner/applicant hereby agrees to hold and save harnr <br /> less the City of Everett trom any and all daims for damages, costs, <br /> � ' � expenses, or causes of action that may arise becau,e of installation <br /> �`—��� <br /> and maintenance of the impwvemenl or olher right-of�way use nereto <br /> / " '��� � ` -'� applied for and fur�her agrees to remove same upon notice irom the <br /> Approved for Con V r(j�n Date City and to replace public nroperty damaged thereby. <br /> - - � -__: . - . . <br /> % <br /> �Ca' j- Z Z -�G '—..__ _ Zz /9Si <br /> FINAL INSPECTION Dale <br /> Approved as Constructed SignaWre oL4pPlicanl Date <br /> everetl PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED A�D THEREAFTEB IS TO <br /> Everett, WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PcRMIT MAY BC- I <br /> Phone: 259�8615 CANGELLED BY THE CITY UPON ANY STOPPAGE 6r WCFK ON THI` <br /> PROJECT OVER 90 DAYS DURAIION. <br />