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DateApplication For <br />PUBLIC WORKS <br />Print or Type Only <br />X D 06,eT 0. �i�RRe <br />Owner <br />—t o 6 <br />N D: <br />M M <br />Public Words Permit is A�JCL_ <br />Bldg Dept <br />Public Works Fee <br />Tctel Fee S <br />Less Appi Fee Paid S <br />n✓ <br />Balance Due Ssj C'- <br />Ev� rr) �✓✓� <br />9 $me- A a sc = o zr <br />Zip Phone <br />S,yn�' _ s/��c"V P�o✓0 1 c�� 6 9G(" <br />Applicant Mailing Address U"ity Zip Phone <br />Describe Proposed Work gd9tLe,,'NG ejV S 7 t'-r- ✓ T S 10 e- l0 008Ve V <br />( FKo 4'r o F ,yo user,) ApoA o r 7 <br />iC 8 77N,t3�LLL�A,c'Xr Tb ZA4w AJJ 4ri eitc'Xr To ZA4w A/�iP/O4ri sit P o 60i<1. er <br />✓CD UJ <br />Project Address (if known)—?nc:5s <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: to <br />• Property Lines • Centerline of street /A <br />• Outline and dimen. Ana of all existing and • Indicate North v♦ <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS O <br />1. All calla for Inspection shall be made 24 hra. in advance - phone 259.8810, <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Cell Location Underground Service 48 hre. before ,ou dig. TOLL FREE NUMBER 1.800.424.5555. <br />Ap�for on 4 ct - - - D Leon 4 ct - - - D tea <br />FI INSPEC 10 r, Date <br />Approved as Constructed <br />W <br />PUBLIC WORKS DEPARTMENT <br />Ever tt, WA Street <br />Everett, WA 98201 <br />Phone: 259.8810 <br />Fail <br />L•J <br />Cl/ <br />a <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to told 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 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 ttoo�replace <br />/public property damaged thereby. <br />ignature of Applicant Date <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 />