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DateAy`."ti.r/ <br />Application For <br />PUBLIC WORKS PERMIT <br />TO POSTING iil l"IL- <br />Print or Type Only <br />Pueim Wod, Mrmx . )1 1_11 <br />Bldg Dept • - <br />Pml¢ Wodn Fee <br />Toles Fee { <br />L!Y April No Pied S <br />B41aece Due 5 -7 c' <br />St-, IY1lPhore <br />Applicant Meiling Address City Zip <br />Describe Proposed Work )P 11) 1; HR <br />Project Address (if known) 15 1 %Z' ti <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable <br />- <br />• Property Lines • Centedine of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 his In advance - phone 259.8810 <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Servile 48 his before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />- <br />Appr/owedd cioir Construction Date <br />FINAL INSPECTI N (" " i "N Dale <br />Approved as Constructed <br />0LPUBLIC WORKS DEPARTMENT <br />0200 Cedar Street <br />Everett. WA 95201 <br />Prone259-6810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />Z <br />O <br />The undrisigned owner/applicant hereby agrees to hold and save harm. <br />less the City of Everett from any and all claims for damages. costs. <br />expenses or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace <br />�public property damaged thereby. <br />gnaturi o! Applicant ' OeID <br />WORK AUTHOR,ZED BY THIS PERMIT MUST BE STARTED WITHIN <br />160 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION, THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />so, r <br />