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Date <br />PUBLIC <br />Print or Type Only <br />Ownei <br />Appllcanl <br />Describe Proposed Work <br />.. Tn vntTlNf, <br />Appliy�tion For <br />WO�KS PERMIT <br />¢ <br />r� <br />� L� C. Ci �O <br />x' �'- csh. u� [- ri C� <br />G" f,l C] I`� O d <br />� 6) CJ [� o�t <br />.r.� M �W + 0�7 M f� <br />�..� F <br />niling rers�s p(�. �p�y. . � <br />y �: fi � O C J O .+ <br />'" M- � :: o <br />�iCir - 3 � I'. <br />Meiling Atldress <br />Proiecl Addiess Iil known) �`--� � zJ---S���-- <br />�Z S-4 <br />O f'1 O <br />tl � m <br />j IF � �• J <br />i�j� <br />City , <br />Puolic Wo�hs Permit � ����' l <br />Biec Deo� • - <br />Pu�l¢Worh�Fee s <br />Tolelfee <br />lef� �00� �ee PeiC S <br />Bah�ce Oue S ��� <br />���21�/ 3.�i� S��/C) <br />Z�p Phone <br />auach lour 141 cooies ol plans lor proposed work • Draw to scale and note the lollowing as applicable�, <br />• Property Lines <br />• Outline and dlmensions ol all ex�sting end <br />proposed strudures on the lot <br />• Eaistlng and proposed ulilities <br />• Centerline of street <br />• Indicate Norih <br />• Show any proposed grnding changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All cells lor inspection shell be mede 24 hre. in advence • phone 259•8810. <br />2. All work shell be pertormed in eccordance with Ihis pe�mit end currenl Cily of Everett DesiBn end Construcllon <br />Stenderds end Specilicelions. <br />3. Cal� Location Undarground Service 4B hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />,5/ �,.,�,�• %�/`�r`.�-�' o%N� �%y�-� 3- 3 a 9¢ <br />Approved as Consiructed <br />�PUBLIC WORKS DEPARTMENT <br />3200 Ceder S\reel <br />Eve�etl. WA P8201 <br />Phone' 259�BB10 <br />ACKNOWLEDG[MENT OF CONDITIONS <br />� <br />� <br />� <br />� <br />O <br />a <br />Th�a undersignr.d owner/npplicunt horeby agrees �o hold and save harm� <br />less Iha Gly ot Everetl Irom any and all claims for damages, cosls. <br />eapenses. or cau5es ol action that may erise 6ecause ol ins�allalion <br />and malntenance ol ihe improvement or olher nghPobway use hereto <br />applied lor end further agrees to remove seme upon nolice irom ihe <br />City anA to replace publ�c prope�ry damaged Ihereby. <br />; ; �' v-i��-yy <br />ighature hc i. Dete <br />BO DAYSTOFO DATE� PERMIT ISE SSUED AND THEREAFTER ISHTO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BV THE CITV UPON ANV STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DUFATION. <br />