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Date �"��� � <br />Application For <br />PU�LIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Mailing Address <br />Mailing <br />City Zip <br />Gity <br />Describe Proposed Work �ti��V � �17�.�-�I i)l(�cr �(�� <br />Prolect Address (if <br />Attach fow (4) copies of plans for proposed work - Draw to scale and note the fo'llowin� as applicable: <br />• Property Lines <br />• OuJine and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed ulilities <br />PERMIT CONDITIONS <br />PubLc Works Permll o <br />1�- <br />914gDep1.+ �^ <br />Puellc WotNs Fen <br />Tolal Fee $ <br />Less Appl Fm Paitl S <br />9alanco Duo 5 <br />• Centerline of street <br />• Indicnte North <br />O Show any proposed grading changes <br />• Show meaaurements <br />Phone <br />1. All calls (or inspection shall be made 24 hrs in advance - phone 259•881 5. <br />2. Ali work shall be performed in accordance with �his permit and wrrent Ciry oF Everett Desgn 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 />��caG/G C�IO.e.ES f�6e�in/T �t%o7� �E�G%�{� <br />� <br />Ppproved for Construction <br />jjs� <br />��r�.,� <br />ACKNOWIEDGEMENT OF CONDITIOMS <br />� <br />� <br />The undersigned owner/applicant hereby agrees to holo and save harm- <br />less the City of Everet; from any and all claims for rfamages, costs. <br />expenses, or causes ol action that may arise becaus= of installalion <br />and maintenance of the improvemenl or other righbohway use hereto <br />applied f�r and furlher agrees to remove same upon notice Irom ihe <br />Date City and lo replace pu�lic property damaged thereby. <br />FIfJAL INSPECTION Date <br />Approved as Constructed <br />evere[t PUBLIC WORKS DEPARTMENT <br />3200 Cedar Sireet <br />� Everett, WA 98201 <br />Phone:259�8815 <br />� �i' � � %-'�F��% �c _�'% <br />` G�u.tr G� ��,. � ��"� ' <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTEU WITHIN <br />180 DAYS OF DATE PERM:T IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MA1' BE <br />CANCELLED BY THE CITY ��ON ANY STOPPAGE OF WOFK ON THIS <br />PROJECTOVEP.9Q DAYS D IRATIO�:. <br />