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Date/ <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Wert. Permit �a �-510 <br />sift Dept a._c—a— G _ <br />Puli Wo" Fee <br />Total Fat S <br />Loa Appl Fee Paid . <br />Bolero@Dun <br />C�jUTr+ LCi1 �r�G-SL�Ei�EXI'�i61'IfL & e5&67 t' - %,fzoq __ S.i s �/v9L_ <br />Owner Mailinti Address City Zip Phone <br />DuJtiler- <br />Applicant <br />Melling Address <br />Zip Phone <br />y <br />Doscribe Proposed Work JVS 'tel^ .99 U140 " tldAlCA&715s �CIlb'ru/1Y <br />V4 <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable <br />• Property Lines <br />it Cenlerlme of street <br />• Outline and dimensions of all existing and <br />at Indicate North <br />proposed structures on the lot <br />/. Show any proposed grading changos <br />• Existing and proposed utilities <br />4 Show measurements <br />HIS LI <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrs in advance - P for .259.8815. <br />2. All work shall be performed in accordance with this permit and Lrrent City of Everett Design and C�nstrurtlon <br />Stacclards and Specifications <br />3. Call Location Underground Service 48 hrs, before you dig. TOL i FEE NUMBER 1-800.424-5555. <br />72, ee- oxY'e- 4S <br />�alf'QCT THE ,11Z)TdCC-.✓T Ptt'crf',ccTiES ktl/7f/ <br />✓r S/!�E-G/dl�+ls AC6 AIOCrJ ubf3r'c tc'if/� A/UY Ddn74C.rr <br />le, TNE/n v'//dLL fJE veeAdi.eeb A;i 7ifF A,01k [dA/7, <br />Appl Dived for Constru: tion Date <br />O,Q— Date �g 4 <br />"INAL INSPECTION <br />f Dproved as Constructed <br />e Pft PUBLIC WORKS DEPARTMENT <br />Ever Cedar Street <br />Everett WA 98201 <br />8201 <br />Phone 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />LU <br />�M, <br />N <br />M <br />z <br />0 <br />r <br />Cl) <br />0 <br />am <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 />expenses, or causes of action that may arise because of mstalla:ion <br />end maintenance of the Improvement o' other right-of-way use hereto <br />applied for and further a reel to rem same upon not.,e Irom the <br />Grry'M to replace p bi property damaged thereby <br />Sigplature of Appllca Date <br />ORK 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 />