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Date SA-5- <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />rNA <br />I..-biro Wdrb rannd • <br />etas owL f <br />gtic Nab Fee ` <br />Twi Fee — <br />La.a bql Fee PaW <br />Balanda pea • 49 D <br />74 T4,T -- <br />Applicant Nailing Address City Zip Phone <br />Describe Proposed Work %7 i/ !c --•, - - ---- ------ <br />9ir,6t�, <br />r� <br />.. <br />r� <br />c- c <br />r•i c <br />F" <br />Project Address (if known) <br />—I <br />Attach four (4) copies of plans for proposed work • Drew to scale and note the following as applicable: <br />•ate <br />x - <br />• Property Lines • Centerline of .treat <br />• Outline and dimensions of all existing and • Indicate North <br />,o <br />> _ <br />proposed structures on the lot • Show any proposed grading changes <br />�- <br />• Existing and proposed utilities • Shov. measurements <br />w <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />1. All calla for Inspection shall be made 24 hra in advance • phone 259.881 5. <br />r <br />M <br />v <br />2. All work shell be performed In accordance with this permit and current City of Lverett Design and Construction <br />o <br />Standards and a <br />48 hire. before dig. TOLL FREE NUMBER 1-800.424.5555. <br />r_ <br />3 y <br />Underground you <br />3. Cell Location Underground Service <br />yf1P�C/CdNT S.Y.oLl. ��'J1��E �},f/f/ Gldnod6iO <br />� <br />� <br />a <br />slo�,GL,t`, c.,�Ea rEO �i/.�/,�v %H� �'O•✓ST.�UCr/0�1 <br />i <br />i�iPOCF $�, �,$/DEt<lDG.GS' A,eE NOW NFv,/ AN <br />a <br />= <br />� <br />O <br />0 <br />H <br />mrn <br />11 everett PUBLIC WORKS DEPARTMENT <br />Over Ceder Street <br />Everett, WA 98201 <br />Phone: 259-6815 <br />ACKNOWLEDGEMENT OFCOI ATIONS <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 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 />?.7 <br />Ig afore of AD Ilc at Dete <br />WORK AUTHO IZED BY T�1!!S�P�R�M�IIT h1 U'iT 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 />