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Date� 1Q 6 <br />r' <br />Applicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />nuu�esa <br />Describe ProposeE Work <br />Project Address (il k�own) <br />1 Pu�hcWodePar <br />I <br />Biap Dept • � <br />PUUbc Work� Fee <br />Totel Fae S <br />Lesf A00� Fea PaiJ S <br />balence Due S <br />UIY Zip <br />Attech four �4) copies of plans lor proposed work • Draw to scale and note the lollow�ng as applicable: <br />• Property Lines <br />• Outline and dimensions ol all exisling and <br />proposed st�uctures on the lot <br />• ERisting and proposed u�ilities <br />• Centerline ol s�reet <br />• Indicate Norlh <br />• Show any proposed grading changes <br />• Show measurements <br />VERMIT CONDITIONS <br />1. All calls lor inspectlon shall be made 24 hrs. in advanco • phone 259•8810. <br />2. All work shail be peRormed In accordance with this permil and current City of Everett Design end Conslructlon <br />Standerds and Specilicatinns. <br />3. Call Locallon Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />ilC�`T (�C�U(�'P� <br />�� <br />7-i9 aa <br />Approved lor Conslruclion Date <br />FINAL INSPECTION Date <br />App�oved es Constructed <br />everett PUBLIC WORKS OEPARTMENT <br />� 32C0 Ceder Street <br />EverelL WA 98201 <br />Phone:259�BB10 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />0 <br />� <br />� <br />0 <br />a <br />The undersigned owner/applicanl hereby agroes to hold and save harm- <br />less ihe Ci7y of Evr.rel� irom any and all claims lor tlameges, cosis, <br />a:penses, or causes ol action that may arise because ol installalion <br />and mainlenance ol ihe improvement or other righl�ol�way use hereto <br />applied for and luriher agrees to remove same upon nollce Irom �he <br />City and to replace public property damaged thereby. <br />Signalure of Applican! Dale <br />WORK Ai1THORIZED BY THIS PEFMIT MUST BE STAqTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEFEAFTER IS TO <br />BE DILIGENTLY PURSUF.D TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />