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Date�?� 7 <br />� <br />Applicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />AppliCant <br />Descdbe Proposed Work <br />Pro�ect Address (if known) <br />�J <br />Address <br />Mailiny Address <br />Zip <br />Puei¢ worws Porm�l • C � p� <br />BIJ9 Dapt� �z�4 ��CT _ <br />iuElicWodeFea s <br />Tolal fae <br />Leas Appl Feo PaiO $ <br />BnlanceDue .S <br />Attach four (4) coples of plans for proposed work • Drnw to scale entl note the following as epplicable: <br />• Property Liney • CeNi�rlina ol street <br />• Outline and dimensions of all ezisGng and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Exlsting and proposed utilities O Show meesurements <br />PERMIT CONDITIONS <br />1. All cells tor Inspectlon shall be made 24 hrs In advi <br />2. All work shell be perlormed in accordance with this <br />Standards and Specificatlons <br />3. Call Locatlon Underground Service 4A hrs. baf , <br />rnone <br />Phone <br />hone 259•8815. <br />ar.d curreM City of Everett Design and Conslruction <br />dig. TOLL FREE NUMBER 1•800•424•5555. <br />I / � <br />� . � � // <br />� �, G / <br />� <br />Approved for Construction Dete <br />FINAL INSPECTION Date <br />Approved as Canstrur.ted <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Evare�t, WA 98201 <br />Phone:259�8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />�� <br />� <br />� <br />L J <br />Th��. undersigned owner/epplicant hereby agrees to hold and save harm• <br />les�� tho City of everett irom eny and all claims lor demages, costs, <br />expenses, or causes of actlon that may arise because ol installation <br />antl maintenence ol the improvement or other righFol-way use hereto <br />appiied lor nnd iu�ther agrees to remove some upon notice Irom the <br />Clty end lo raplace public properly damaged thereby. <br />Sign 3ture ol Applicant Dale <br />WOFK AUTFIORIZED BV'fHIS PERMIT MUST BE STARTED WITHIN <br />1H0 7AYS UF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br />BE D'LIGEN'LV PURSUED TO COMPLETIO.J. THIS PcRM1T MAY BE <br />CANC ELLED BY THE CIN UPON ANY STOPPAGE OF WORK ON THIS <br />PROJ�CT OVER 90 DAYS DURATION. <br />