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Date <br />Appllcation Fot <br />PUBLIC WORKS PERMIT <br />Plan Check Nos C 45300 SEPA <br />Appllcat.Date: OB/17/94 <br />Print or Type Only sob naareee: 114 �5TH ST SW <br />Owners FIT25IMMONS HICHAEL <br />Tenants <br />Propoaed Uee: SINCLE FAMILY RESIDENCE <br />Deec. of Work: <br />BEDROOM 6 BATH ADDN <br />Owner <br />Applicent <br />De�acribn Froposed Work <br />Project Address (il known) <br />OFFICE SET JOB SET <br />APPAOVED FOR PERMIT: DATE_/_/_ BY <br />Pu�i¢ Wo�h� Permn • <br />9iCp. DeO�- � _ <br />PuEec Wors� Fea <br />To��iFae s <br />leu Aoo� Fee P�ie S <br />B�i�nn Oue s <br />ip Phone <br />:ip Phone <br />Attech lour (4) copies ol plans lor proposed work - Draw to scale and note Ihe lollowing as applicable: <br />• Property Lines <br />• OWiine and dimensions ol ell e��sting and <br />proposed st�uctures on Ihe lot <br />• Existing and proposed utllities <br />• Centerline of slreel <br />• Indicale No�th <br />• Show any proposed grading chenges <br />• Show measurements <br />PERMITCONDITIONS <br />1. All calls lor Inapection shell be mede 24 hrs. in edvance • phone 259•8810. <br />2. All work shall be perto�med in accordence with this permit and current City ol Everett Deslgn and Constructlon <br />Stendarda end Speclficetions. <br />3. Call Locetian Undarpround Service 4B hrs. belore you dig. TOLL FREE NUMBER 1-800-424•5555. <br />Approved lor Consiruclion <br />FINAL INSPECTION <br />Approved es Constructed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everetl, WA 3B2J1 <br />Phone:259•8810 <br />PUDLIC WORKS PERMIT <br />N T HEOUIREtI <br />'1 Y l> <br />�nTE g i 7 k <br />ACKNOWLEDGEMENT OF CONDIilONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersignetl owner/applicanl here6y agrees �o hold and seve harm� <br />less the Clly ol Everett Irom any and all claims lor damages. cosls, <br />ezpenses, or causes ol aclion thal may arise because oi inslallation <br />and maintenance of Ihe improvemenl or olher righl�ol�way use hereto <br />applied lor and lurther agrees lo remove same upon nolice Irom the <br />Date City and to repiace public property damaged thereby. <br />Date <br />Signelure ol Applican� �ale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STAFTED WITHIN <br />180 DAYS OF DATE PERMITISISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANGELIED BY THE CITY UPOIJ ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />