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i <br />Date � ,-=J-1S-; . <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />!'7L�/,'! �'Jl�l �r'1 <br />Mailing Address <br />.� / � <br />f, �- <br />Mailinq Address <br />Describe ProPosed Work � l`�!'( �' 1�,�--f.''� � c.-�'�(� '��� �--.. <br />Proiect Address (if known) <br />Pu01ic Works Pormil < ��/�� ��� � <br />_ • �'-`_�� <br />BI09. Dep�. s • � : <br />PuOlic 1Yorks Fev 5 <br />Tatnl Fcc <br />Loss A001. Fec Paid g <br />Balance Duo $ ,�5y Sn <br />= -j.5/,'_'� <br />_ ZiP <br />� . <br />�li//'�� / c �';� <br />r Zip <br />Attach four (4) copies of plans for proposed work - Draw to scale �nd note ihe following as applicable: <br />• Properry Lines .• Centerline of street <br />• Outline and dimensions ol all existing and • Indicale North <br />proposed structures on the lot • Show any proposed greding changes <br />• Existing and proposed utilities • Show measuremenis <br />Approved <br />�/� <br />� :�� <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advance • phone 259-88 i 5. <br />2. All work shall be performed in accordance with this permit and current City of Everetl Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424-5555. <br />�O �t <br />/%HTFG> <br />CO.L�S Tk'vlTFo /�c i� .AP��c«.'r J <br />(n -/G - 5' ' .. <br />�SSiTc /JG��� <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />��f���iGG�i✓: T- f�/_.'C�'✓.OF' /t-.c'iZr'n;i�i4�e � <br />.i�: i: rr % �/'.!J'L°U{�t�/�7C/�/ f Ci(.� i�C�_ L y l��. —_.'"— <br />� _� O <br />�_ a <br />Approved as Constructed �J " <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259•88 7 5 <br />/ / Date <br />�z9 �g �, <br />Date <br />� ur,: � ,✓-� <br />f"� ,� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the City of Everett from any and all claims tor damages, costs, <br />expenses, or causes of action lhat may arise because of inslallation <br />and mainlenance of the improvement or olher righFof-way use hereto <br />applied for and further agrees to remove same upon nu:ice from ihe <br />Cily and to replace public property damaged thereby. <br />Si a i of A plicant' --�7 �� Date <br />W RK AUTHORIZED BY IS RMIT MUST FiE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED ANC THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. �fHIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />