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Date �� 1 % <br />Applicelion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />��v <br />A;��� �-o <br />A�>,��, on - <br />Pub��c Worwe Permn . / / 7 � �', <br />Biap �eo� • <br />fee <br />iolp fne i <br />Leu�o0l.fenPUE s 'J/ <br />BSlenceDue s �7" �" <br />nn:-;r.��Yc/�;r> / <br />�'yn- ;Fa�nn/- 77% <br />Applicent Melling Address City 2iH Phona <br />DescribeProposedWork vrdc�� drJrn � � ����/� /e S/rtcT rlra�n3ut- ���1�. <br />�� tG/� <br />� <br />Project Address (il knowN / �U �j '� <br />Altach four (4) copiea o� pla�s lor proposed work • �raw to scale and note Ihe following as applicable: <br />• Property Linea <br />• Outline and dimenslons ol all ezisting end <br />prnposet slructures on the lot <br />• Exiating and proposed alititles <br />• Cenlerline ol street <br />• Indicale Narth <br />• Show any proposed grading changes <br />• Show measuremenis <br />PERMIT CONDITIONS <br />1. All calls lor Inspection ahall be mede 24 hra. in edvence • phone 259•8870. <br />2. All work shell be perlormad in accorAance wilh thia perndt and current City of Everett Design and Construction <br />Standards end Specilicationa. <br />3. Call location Undarground Service 4B hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />ij /Lfr.4:.�J. <br />� ���� X,,. <br />�2,»u �8G <br /><rny�..e..�E+ni .cc�c:fi�i ,.�2tc�ccn.•1- �t<r' <br />� <br />S l''/�/±��.�..� �c�.ec�!'�l.l'�i- .� :r� -e,.f _f��, �f�., ,�7; - <br />I 1 � ( (�)YI /lI � <br />�Je.t.a�1'�� �e,� �Ot.v iC'o-�Z' SA'-rY e.1. n�.7� %, /J'Ni ..,.ed' <br />�j� � 1/ .it I�f� i'.J- Yi'. � lr>� .�'(�a+.�. <br />��r�PUBLIC WORKS DEPARTMENi <br />3200 Cedar Street <br />Eve�e16 WA 98201 <br />Phone: 259-8810 <br />ACKNOWLEDGEMENT OF CUMDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersi�7ned owner/epplicant hereby ayrees �o hold and save harm� <br />less ihe City ol Everelt irom any and all cleims lor damages, cosis. <br />expenses, or causes ol ac�ion that may arisa because of installetion <br />and mainlennnce of the improvemenl or olhe� righl�ol-way use herelo <br />apPlied lor and lurther agrees to removo same upon noticr. irom Ihe <br />City and to rcplace pubhc p�operty damagod ihereby. <br />���.lL �.�. � �F" - <br />Signature ol Applicant Da1e <br />WORK AUiHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAF7ER IS TO <br />BE DILIGEN7LY PURSUEO TO rOMPLETION THIS PERMIT MAY BE <br />CANCELLED BY TfiE CITY UPON ANY STOPPA3E OF WOFK ON iHIS <br />PROJEC7 OVER 90 DAYS DURATION. <br />