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Date—l.ix�n� <br />V.� App�icatlon For <br />Pl1BLIC WORKS PERMIT <br />Print or Type Only <br />Meiling Address <br />/ -_ �c�- � <br />^ � <br />Pu01¢ Worke Permn • <br />aiao. oeo� • <br />PoDbc Workt Fee � <br />Toltl Fee s <br />Le��ACG�Fc. Pu0 s <br />B�bnce Due .i <br />Zip <br />��ao3 <br />App icanl � Mailing Address City Zip Phone <br />Desc�ibe Proposed Work <br />Proled Address (if known) <br />Attach Icur (4) copies of plans for proposed work • Draw to scale and note the lollowing as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicale Norih <br />proposed atructures on the lot • Show any proposed prading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shell be made 24 hrs in advance - phone 259•881 5. <br />2. All work shall be performed in accordance w�,th this permit and c�rrent City of Everelt Design and Construction <br />i•andards and Speclfica�ions. <br />3. Call Location Underground Service 4B hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�!�G/C L��J,e,�--� f��f�ii �r/oT <br />��cvi��Ev Fo,� Sy� ���� <br />� �-. <br />/ a6�7 <br />����.��,��T s9y.s 7,s �,<< <br />!�E y �S�'.�o� - 21�i .9 l�/iz.✓GE": <br />Approved lor Consiruction Date <br />FINAL INSPEC710N Date <br />Approved as Constructed <br />everett PUBLIC WCRKS DEPAR7MENT <br />� 3200 Cedar Sl�eet <br />Eveiett, WA 98201 <br />Pho ne: 259-BB 15 <br />ACKNOWLEDGEMEN'f OF CONDIYIONS <br />� <br />� <br />� <br />� <br />� <br />I"" <br />� <br />� <br />a <br />lhe undersigned owner/applican� hereby agrees to hold and save harm� <br />less the City nl Everett from any and all claims for damages, wsts, <br />expenses, or causes ol action Ihat may arise because of ins�allation <br />and maintenance ol the improvement or olher right�ol-w�y use hereto <br />applied for and lurther agrees lu remove samc upon nolice from the <br />City and to replace public property damaged Ihereby. <br />- ��n��� <br />5 g tu ol Applicanl Dale <br />WORK AUTH��RI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF C�TE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PUFSUEO TO COMPLETION. THIS PERMIT AAAY BE <br />CANCELLED BY TI1E CITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />