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Date�,��' q pp <br /> PupLc WorFs Pormil�I�7��� <br /> Application FOr Bltlp.Depl.�_� � Fj,sL <br /> PUBLIC WORKS PERMIT Pu�li�Wo�ks�ee <br /> Totqi Fee S_-_ <br /> Print or T Tp POSTING 'I�.`� -- �essnpni FeePa�n S-� <br /> ype Only Balanc¢Ooe S�Q �O <br /> 1-1,QL1—�(?��A .n/! oZ3ay /YIa,� � ��i �n / �✓J 7�0� <br /> Owner J Mai4ing qddress �i�y � ��3 i� a <br /> Z�p Phone <br /> SR�lr p <br /> Applicant Mailirg Address Cily <br /> Zip Phone <br /> Descri�e Proposed Work � <br /> Project Address l�� known� 1 � �p��r n /� � <br /> Attach four(4) copies of plans fnr proposed work- Draw to scale and note the lollowing as applicable: � <br /> • Properry Lines • Cenledine ol stieet _ <br /> • Outline and dimensions of all existing and • Indicale North � <br /> proposed structures on the bt • Show an <br /> • Existing and proposed utilifies Y Proposed grading changes <br /> • SYow measurements <br /> DO NGT WRITF BELOW THIS LINE � <br /> PERMIT CONDITIONS O <br /> 7.All calls for inspection shall be made 24 hrs.in advance-phone 259•$810. <br /> 2.All wark shall be performed in accordance with ihis permit and current City of Everett Design and Construction ' <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800�QQ4•5555. <br /> �/ // � <br /> � �Dl.�Pi �G¢u-nc ,.C,GjzccQc��Y � ' prc ��lox(4: O <br /> �.� ite�a.�� �•-ti:�Y �-uCP �� � � <br /> '�-C�a�i.O'�3oS'�3o/n 4,,.,���.c'2' See��n� 3,-�J cv��v � <br /> � � �� c,��Ch.o� '7vi�t�cv<7_l� V♦ <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersi�ned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Everetl from any and all claims for damages, costs, <br /> /� expenses, or causes of action ihat may arise because of installation <br /> L/�,�/� � 9 9i� and maintenance of the improvement or other right-of�way use hereto <br /> Approved tor Constr tion �s= applied for and furiher agrees to remove same upon notice from the <br /> Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed <br /> Signature oi Applicant Date <br /> everett PUBLIC WORKS DEPAR7MENT WORK AUTHORIZED BY THIS PERMIT MUST BE S7ARTED WITHIN <br /> � 3200CedarSireet 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS 70 <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT M.4Y BE <br /> Phone:259•8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />