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i <br /> ! <br /> � ✓ <br /> .I <br /> �����,nry,. � �jE7�T TO F+���Nb (��- <br /> DateL1L./—/_1Lf_ � Pubi�c Works Parmit� �-" � <br /> . � �—e.-90 a,�, oeo, .�?�a -- <br /> Application For r <br /> PUBLIC WORKS �ERMIT °°°;o;;Fee°aa : --- <br /> � less FpPI.f ne PaN S _. <br /> Print or Type Only � $ $ ea�a�=eo�d S�S� - <br /> .�i M � <br /> O � � <br /> �Iw,�L�uo�� T /rn �� .� lni .'�o/�!i»�GOG`v �vPil� QdzOl aZS�-(e �/ , <br /> Owner Mailing Addre a � � � � C�ty Zip Pho e i j <br /> � �$ <br /> �V/cP NlQs J�/'��e i e���Ai�i,7i��'�/��,�iniaY� �d'2D� ,2SQ 3i(�j/ I <br /> pppli� Mailin�Atldress Ci�S' LP � Phone <br /> Describe P�oposed Work �a.�An� � DIrY�✓Q./'j�J„�M�"" .9N�0 .S/TE G✓O,C�(" <br /> � / W <br /> ProjectAtldresslifknown) 7� ���� N��� �"✓'�' � <br /> Attach four(4)copies of plans lor proDosed work- Draw to scale antl note the tollowing as applicable: � <br /> . • Properry Lines • Centerline of street � <br /> • Outline and dimensions ol all existing and • Indicate North <br /> . proposed structures on the�ot • Show any proposed gradi�g changes <br /> • Existing a�d proposed utilities � Show measuremenis � <br /> � DO NOT WRITE BELOW THIS LINE O <br /> � PERMITCONDITIONS <br /> �� 1.All Calla for inspectfon shall be made 24 hrs.in advance•phone 259-8810. � <br /> � 2.All work ahall be periormed in accordance with this permit and curcent City of Everett Design end Constructlon <br /> � Stenderds and Specificatfons. <br /> 3.Call Locatlon Underground Servico 48 hrs.before you dig.TOLI FREE NUMBER 1•800-4245555. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> I,� ACKNOWLEDGEMENT OF CONDITIONS <br /> �� The undersigned owner/aF?licant hereby agrees to hold and save harm� <br /> less the City of Everetl Irom any and all claims lor damages, costs, <br /> A /� rv expenses, or causes of action that may arise because of installation <br /> �'1/ � �-�/ � `�,��.��� and maintanance of lhe improvement or other righFOf-way use herelo <br /> � Cw Y � ��>�, l applied for nd further agrees lo remove same upon notice Irom the <br /> Approve lor Const ctlon Date City and replace public properry damaged thereby. <br /> /- 2 -so � <br /> FINAL INSPEC7;ON Date d [R <br /> Approved as Constructed Signalure ol Applic t Date <br /> everett PUBLICWORKSDEPARTMENI WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WI7HIN <br /> � 3200CedarS�reet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br /> Everett,WA98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />