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Date (� ' ��L � <br />Application for <br />F�UBLIC WORlCS PERMIT <br />Print or Type Only <br />_ fi��r.ocyc-n .voiE:� <br />I�46 - Z9s <br />Public Works Permll [+ <br />91tlq.Deot � ____sl�__C�%��� <br />P., '^<sFee <br />�IFt� s <br />Less A00�� Fea Paitl S <br />eam.��e o�a S �� �' <br />✓a/AJ� G1//a- 9�'��_ �5 a -�f� <br />City Zip Phone <br />" Applicant Maiiing Atltlress cny up rnone <br />3zzo - s� �`h <br />Proiect Address (if known) <br />Attach four (4) copies of plans for preposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of sireet <br />• Outline and dimensions ot all existing and • Indicate North <br />proposed structures on the lot • Show any pi oposed grading changes <br />• Existing and proposed utilities • Show measuremenU <br />. <br />DO NOT WRITE BELObY ThiIS LINE <br />PERMIT CONDITIONS <br />t. All calis for inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in accordance with this permit �nd current Ciry of Eve�elt Design and Construction <br />Standarils and SGecifications. <br />3. Call Location Underground Service 48 nrs. belore you diy. TOLL FREE NUMUEF ?-b00•424-5555. <br />f� .�E�>o�� Exisri�v�r <v.ed� cul7Fa. � Sincw.9�k <br />AT 7�.PivEtJAy E:u7.Pq�;✓C�' fjie/� ,�''E,Q;9C.6 �,✓� TH <br />Fv�c NEiG//T Car�d �{.fv�2 f�e,e G'iry �r,9,vaA2,�J <br />#f .3G 5 � 30l0 . <br />.S C�ONS�QUcT il/E�+J i�.2%v'caJ�r/ <br />�.307 <br />���TZ� � � �6 <br />Approved for Const uction Date <br />��j ,�/�r �� /l.il -�G <br />FIN INSPECTION Date <br />Approved as Conslructed <br />eve�a[t PUBLIC WORKF DEPARTMENT <br />� 3200 Cedar S!+eet <br />Everett. WA 98201 <br />PliOne: 25P-8815 <br />P6.� CiT` S?y.t//lo�d <br />ACKNOWLEDGFMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett Irom any and all claims for damages, cosis, <br />expenses, or causes of action tha� may arise 6ecause of installation <br />and maintenance of the improvement or other righbof-way use hereto <br />applied for and further agrees to remove same upcn notice from the <br />City and to repldce public property damaged �hereby. <br />_ 1 � �_ _�- �- R � <br />Sig ature of pplicant Uate <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />lA0 DAYS OF DATE PEqA71T IS ISSUED AND THEREAFTER IS TO <br />BE DILI�ENTIY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DA'IS DURATION <br />