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Date, <br />Application For <br />PUBLIC WORKS �ERMIT <br />Print or Type Only <br />Mailing <br />- � n <br />12 L <br />Meiling Address <br />Describe Proposed Work <br />Prolect Address (if known) <br />z� 5� � % <br />Public Works Perm��/� <br />81Eg. Dapt. • <br />Pu01ic WorkS Fae S� Q� <br />TatalFeo <br />�— <br />Lass ApO� Fae Paid � — <br />Balance Duo 5 2Q � V�_ <br />Attach four (4) copies of plans for proposed work - Draw lo scale and note the following as applicable: <br />• Property Lines • Centerline of sireel <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot O Show any proposed grading changes <br />i Existing and proposed utililies • Show measurements <br />75 /�� <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be per(ormed in accordance wilh ihis permit and current City of Everett Design and Consiruction <br />5[andards and Specifications <br />3. Cail Localion Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424•5555. <br />�.�L Occ>��� �v/GL E,�Cfl�iic�' cX/.S'T/�G AS'��Yf,'GT 77F� <br />, .D'�'E //t! il �%�J'�� �SL/5` /v 'v' �'/��9�3' f L�n) G' <br />�J d �,J, ffi�,D ,�EF'�i9�'c w/TiS� � C'�'�i^�1-"� <br />C�/��r:viir/� �ryiJTiiJG� ,89�� /�%rCc�ci� <br />oF L Ut-J <br />�0�,� /iT�L.T.�'� �i�/c'cHiT�c�' GE�� ��' <br />� <br />FINAL INSPEGTION IJ � <br />Approved as ConsVucted � <br />everett FUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />� <br />Date <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />pr� <br />V♦ <br />� <br />� <br />The undersigne� owner/applicant hereby agrees to hold and save harm- <br />less the CiIY of Everett trom any and all claims (or damages, costs, <br />expenses, or causes ot actlon that may arise because of installation <br />and maiMenance of the improvement or other right-ohway use hereto <br />applied for and (urther agrees lo remove same upon notice from [he <br />Cily and to replace public property ±amaged thereby. <br />�� ' \a �1 d�.�9,9--�, �' $�/d`� <br />c� <br />Signature of A p41ca t —%� Date <br />WORK AUTHOR�ZED BY THIS PE7M1T MUST BE STARTED WITHIN <br />180 DAYS O'r DATE PERMIT IS ISSUED AND THEREAFTEq IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED 8Y Th1E CITY UPON ANY STOPPAGE OF WORK UN THIS <br />PROJECT OVER 90 DAYS DURATION. <br />