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•, ���/ � — q� '� � Pub11c Wa�ks Permit� <br /> D'ate g/_a <br /> � Bitlq.Depl.+� <br /> - Application For <br /> PUBLIC WORKS �'�R11411T PUbTallFneFee g <br /> Less AOoI.Feo Peitl $ <br /> Balance Duo $_ <br /> Print or Type Only / ,?£ <br /> o�eZ�Y�.JJ <br /> CV ��A N iv i �A 't7"v(-14 �03(� J�vG' 1'Q�U l.c�^ Cl� ��r �6203 <br /> Owner Madmg Address Zip Phone <br /> h �`J�MDio�t/ �s�'n�- �o/ �. �rJ (v� g8ao/ o2S�'-.�i.�_ <br /> Applicant Mailmg Address City Zip Phora <br /> Describe Proposed Work <br /> �t�'��� — //D�/�r./!�,n'ff' _ <br /> �SD�3� �irs �'f W <br /> Project Address�if k��uwn) ��" � <br /> Attach four(4)copizs ut plans for proposed work• Oraw to scale and note the following as app� able: � <br /> • Property Lines • Centerline of street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed structures on the lot • SYow any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259-881 O. <br /> 2.All work shall be pedormed in accordance with this permit and currer.t City of Everett Design and ConsL•uction <br /> Stand�rds and Specifications. � <br /> 3.Call Lucation Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424-5F i5. <br /> � <br /> � � <br /> � <br /> O <br /> , <br /> , R, a <br /> � g 3'S <br /> � � ACKNOWLEDGEMENT OF CONDITIONS <br /> �.' <br /> The undersigred ownedapplicant hereby agrees to hold and rave harm- <br /> less the City of Everett Irom any ar�d all claims tor damac es, costs, <br /> expenses, or causes of action ihal may arise because of installation <br /> � and mainlenance ul !he improvemenl or other ric�ht-ol•way use hereto <br /> applied for and lurther agrees to remove same upon notice irom the <br /> Approved for Construction Date Ciry and lo replace public property drmaged thereby. <br /> FINAL INSPECTION Date Date <br /> Approved as Constructed Signature ot Applicant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN! <br /> evere[t PUBLICWORKSDEPARTI�AENT 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PUFSUED TO COAIPLETION.THIS PERMIT MAY BE <br /> Cverett,WA 98207 CANCELLED BY THE CITY UPON ANY STOPPAGE O�WORK ON THIS <br /> Phone:259•8810 PROJECT OVER 90 DAYS DURATION. <br />