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i <br /> I <br /> � <br /> Date_��"� "�� 1 �, 7 � <br /> Pu�Lc Waiks permit+ � <br /> < �J�'�''�Z� <br /> Application For eieq.oeo�-• - J / 1 � /(x�--i <br /> PUBLIC WORKS PERMIT P�����W��ksFa� <br /> Tolsl Foo S <br /> Le3s AppL Fee PniE s <br /> I <br /> Print or Type Only eai���ao�� s l2.lf� <br /> , <br /> l�l� ������rc� ��,s,��. �'ir�l C"��,�ik��s ��-� ��.�;� <br /> Owner Mailing Address Cily Zip Phone <br /> 151���1�� �'t�r"l�fi i,��7nL �I�stl� /�i�� �l� 1��1%1�uL � ?� <br /> A licant � Mailing Address Ciry Zip Phone <br /> Describe Proposed Work ��I�� �/ 'n,�� <br /> �� � W <br /> Project Address(if known) L� L—\� !— � .� � <br /> Attach four(4�copies of p�ans for proposed work• Draw to scale and note the lollowing as applicable: � <br /> • Property lines • Centerline of street � <br /> • Outline and dimensions of all existing and � Indicate North <br /> proposed sl�uctures on the lot • Show any proposed grading changes <br /> • Ezisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE <br /> PERMIT CONDITIONS O <br /> 1. All calls lor inspection shall be made 24 hrs. in advance- phone 259•8815. � <br /> 2. All work shatl be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specifications <br /> 3. Call Location Underground Service 48 hrs. belore you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> ! ��f:�i�C /�iN.O .FFpLACF' S.pEliFi�L.t ,ACQ�t/[G- O <br /> F, '�'o.v.-fi'G� i9s .f'�'lnG.,.L.=.CJ : <br /> `�` �a.3t iC u/U,c'.C--� IN.Si�egTo.C' <br /> . � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONOITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less the City of Everett �rom any and all claims for damages, costs, <br /> /- expenses, or causes ol action that may arise hecause of inslallation <br /> y �`� and mainlenance ot the improvement or other right�o4way use hereto <br /> App o lo Con ctio apphed for and further agrees to remove same upon notice from the <br /> / ./' ale City and to replace public property damaged thereby. <br /> (/ <br /> �� <br /> / � \ � <br /> S CTION Date (��'lLi�.SG .�.� ��.- .>��%c.: �� /��>�(�` <br /> Approved as Consiructed Signature of Applicant � Da�/ <br /> ;, <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHOAIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DA7E PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Fverett,WA 98201 BE DILIGENTLY PURSUEO TO COMPLETION. THIS PERMIT MAY BE <br /> I'hone: 259�8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DA'!S DURATION. <br />