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� Date `//�� ��; ��i�� <br />I� Application For <br />' PUBLIC WORKS PERMIT <br />Print or Type Only <br />i <br />�✓\ <br />� �✓ � i_: - � - <br />� , <br />'� ��� 1 l� � �1� �� �� I <br />.� Applicant <br />I Describe Proposed Work <br />, ! <br />_vr/, <br />Mailing Atldress <br />�' <br />�, � n�,a i .'� i ti.�;5 ,� <br />Mailin9 Address <br />City <br />Public Woik9 PO�mll n ��� � �/�`-' <br />BIa9. oco�. k _ ��� "'�/ �[�L'.� fn <br />Publlc Wa�ks Fec <br />To�ol Fae S <br />Less ApO� Fce P�id $ <br />polance �uc �u "l �� <br />-�70?-� �j,_�- � <br />Zip Phone �� <br />i <br />'/ l � � �. t�� `�f,v'� I ,' <' ; e7-c,7/%' <br />Zid"� �Phone <br />, ProjectAddress(if known) � ��. % - � %.�s9 �� _ <br />� Atlach four (4� copies of plans for proposed work - Draw to scale and note U�e following as applica6lc: <br />I • property Lines • Centerline ol street <br />�� • Outline and dimensions of all existing and • Indicate Norih <br />' proposed siructures on ihe lot • Show any proposed grading ch�nyes <br />• Existing and proposed utilities • Show measurements <br />i <br />� DO NOT WRITE BELOW THIS LINE <br />i <br />PERMIT CONDITIONS <br />�� t. All calls (or inspection shall be made 24 hrs. in advance - nhone 259•881 5. <br />� 2. All work shail be performed in accordance with Ihis permi� and current City of Everett Desi9n and Construdion <br />� Standards and Specifications. <br />,, 3. Cell Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•4Z4-5555. <br />i <br />� <br />— _' f . �-p�T.[� • ��. �✓ <br />Approved for Consiruction , � ate <br />FINAL INSPECTION Date � <br />Approved as Constructed � <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett WA 98201 <br />Phone: 259-881 5 <br />ACKNOWLEDGEMENT OF CONDITIONS � <br />The undersignetl owner/applicant herehy agrees to hold and save harm� <br />less Ihe City of Everett Irom any and all claims for damages, costs. �� <br />expenses, or causes of ac�ion ihat may arise because o( installation ; <br />and mainlenance of �he improvement or other right�ohway use hereto � <br />apPlied for and further agrees to remove same upon no�ice from the <br />City 3rfd to replace public property damaged Ihereby. i <br />% �:: K..% � I <br />�� <br />i l�///��� ,C , r -�.,°r«�e/� J •�!��� - 'U- �Y� � <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT h1UST BE S7ARTED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DIL!GENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PflOJECT OVER 90 DAYS DURATION. <br />