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M <br />Date'>�;LL'_e <br />f <br />L' 8 ZS -S <br />PuoLc Work, Penn <br />a 90 y <br />Application For8 <br />Bldg o"l e <br />D 1 yo <br />PUBLIC <br />WORKPERMII' <br />Pueiic WPrhe <br />-- <br />Fes <br />T0181 Fee <br />S <br />Print or Type Only <br />Q <br />V <br />Dr <br />L.I. APPI Fee Perd <br />o $ $ $ $ $ $ J Bebnce Due <br />_ <br />S <br />S l <br />•"r <br />p <br />VI C'J .tea CCd Ifl <br />P <br />(J <br />.r <br />�t(�(77 N <br />N <br />p N N �ryy N <br />r_�E ✓fGe/�iA <br />w/r <br />/i•d• r� <br />Ov^. <br />pTa—�_-� X-�r? 4a-1'Le'Ou S/°Q �✓ y <br />Mailing Adessl _ <br />��33 u�lp <br />do <br />? ST o 0 <br />Phone <br />01 <br />Ly` q 803 7 <br />Anr,l i <br />Malting Address City Zip <br />Phone <br />Describe Proposed Work zz <br />&/ .s F of <br />Project Address (If known) 2.341111 /2— % i/ '�" ST nE <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• P. aperty Lines • Centerline of street <br />• Outline and dimensions of all existing w • Indicate North <br />Proposed structures on the lot • Show any proposed grading changes <br />40 Existing and proposed utilities • Show measurements <br />UO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrs. in advance - phone 259.8810. <br />2. All work shell be Performed In accordance with this permit and current City of Everett Design end Construction <br />Standards and Specifications. <br />3. Call Location Underground Survice 48 hr& before you dig. TOLL FREE NUMBER 1-800.124.5555. <br />ai <br />Approved <br />Approved as Constructed <br />even'tl <br />PUBLIC WORKS DEPARTMENT <br />3200 Coder Street <br />Everett, WA 98201 <br />Phone: 259.8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />CIO <br />Go <br />O <br />n <br />z <br />O <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages. costs. <br />expensesor causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of App Tcant -pate <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />