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��� <br />��� <br />C H <br />AHx� <br />HxF� <br />fC c) <br />H x1 <br />�H�i1 <br />C/� H <br />H 'E" <br />�HCy <br />Q F-1 �y <br />� �T] b <br />�V � <br />9H� <br />r� z <br />Hy <br />gy <br />�e� <br />� � � <br />ZHp� <br />HOcn <br />I'�� <br />"� s� <br />Date_.�' z (/.=� <br />Appiica�ion For <br />PUBLIC WOR�S PERMIT <br />Print or Type Only <br />runi¢wurxsPcrm�iv __. <br />eioe. owi.. civ /o'� Y'/9`/ .. <br />/ <br />aueiic works Fee <br />ToialFee $ <br />LessAnN FeeVa�ia S <br />Baiancc Ouc 5 <br />Jc« �iiao��eT /o/�s"- /9�� �r sE- �Szo� �.�7- 3S"iY <br />Owner Mailing Address City Zip Phone <br />Applicant <br />Address <br />Describe Pronosed Work �-.�c�.�� >- �2'- �i S• F•.�' <br />Project Atldress Id known� <br />Zip Phonc <br />Attach four (4) copies of plans lor proposed work - D�aw to scale and note the fnllowing as applicable: <br />• Property Lines <br />• Ou�line and dimensions o� all �xisling and <br />proposed sirucWres on the lot <br />• Ezisting and proposed utilities <br />• Centerline of street <br />• Indicate North <br />• Show any proposed gratlin9 chan9es <br />• Show measurements <br />IS LINE <br />, PERMIT CONGITIONS <br />! • 1. All calls for inspection shall be made 24 hrs. in advance- phone 259•8810. <br />;� 2. All work shall be pertormed in acwrdance with this permit and current Ci!y oi [verett Desi9n and Construction <br />Q � Standards and Specifiwtions. <br />'4 � 3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800-424•5555. <br />__ <br />� s <br />-��, � ���� ���< <�- �--- ��� � <br />Approved lor Cons�ruction <br />RNAL INSPECTION <br />Appraved as Consiructed <br />everell PUBLIC WORKS DEPARTMENT <br />� 3200CedarStreet <br />EveretL PJA 96207 <br />Phone:259-�f310 <br />-��--�--- <br />� 8� <br />G --. _ <br />ACKtJOWLEDGEi�1ENT OP CONDITIONS <br />�.:�: <br />'� <br />e <br />The under�i9ned owner/applican� hereby a9rees to hold and save harnr <br />less ihe City of Everett Irom any and all clairr�s lor dama9es. cos!s. <br />expenses, or causes of action that may arise because ot inslallation <br />and malntenance of !he improvement or other ri9ht-ot-�vay use hereto <br />applied lor and further agrees to remove same upon nohce Irom ihe <br />Date City and to replace public property damaged ihereby. <br />Date <br />SignaWre of Applican! Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITI-IIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COAIPL[TION. THIS PERh11T P.1AY Ei[ <br />CANCELLED BY THE CITY UPON AWY STOPPAGE OF VJORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />