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Date�_�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />C7 <br />Appheant Malling Address <br />v„��„�, w�,..� �,,.,m�� �'} �7p <br />iaina o�•oi . _� -lJ(..�-J-C�� _ . <br />PrGi¢ Wor�n fee <br />,��,� F�� s _. <br />�essann� FeaPa�� S — <br />[!�i.,n�n Dur S <br />Phone <br />Gty Zip <br />Describe Proposed Wurk __����^ I` „ 6��-" `� -- <br />Prolec� Address lii known) � l U � ��—=—� '�=—`-1Ji-=-�1-i`=�+— <br />✓ <br />Attach lour i4) copies ol plans lor proposr.d work - Draw lo sca�e and n�te tha lollowing as applicable: <br />• Property Lines <br />• Oulline and dimensions of all existing and <br />proposed sVuctures on ihe lot <br />• Existing and proposed utilities <br />Approvedlor <br />• Cenlerline oi streel <br />• Indicate Norih <br />• Show any proposeA grading changes <br />• Show measuremenls <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advan:-e - phone 259•8810. <br />2. All Hork shall be peAormed in acwrdance with this permit end current Cily of Everr.tt Design end Consiruction <br />Standards and Specilications. <br />3. Call Localion Underg�ound Service 48 hrs. before you dIE. TOLL FREE NUMBER 1•SQO•424•555. <br />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />EveretL WA 99201 <br />Phona:259�8010 <br />r1-�T I�C� <br />%� d� <br />3-�.�-8� <br />AGKNOWLEDGEMENi OF COND�TIONS <br />W <br />H <br />�w <br />7 I <br />� <br />0 <br />� <br />� <br />0 <br />a <br />The unde�sl9ned owner/appiican� herr.by agrees to hold and save harm� <br />� less the Gty ol Everelt Irom any and all claims for damages. cosls, <br />eapenses. or causes o� action that may arise because ol installalion <br />and malntenare ot Ihe imnrovement or other righl�ol�way uso hereto <br />applled lor ano 'nriher aprees to remove same upon notice Irom ihe <br />Date City and In replace public pronerty dama9ed Iherehy. <br />Date — <br />Signature ol ApUlicant Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 CAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO GOMPLETION. THIS PERMIT MAY BE <br />CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />