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Date ///251X <br />• / _ Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mailing <br />Mailing <br />Describe Proposed Work _ CdtiSr�'UCT .li/i.�-�G EX <br />Protect Address (if known) <br />a _ <br />Zip <br />Publm_ Works Permit e w _ /� <br />Bldg Dept 7_90/ <br />Pub' o Works Feu <br />oral Fee $ <br />Leaf appi. Fee Pud $ <br />Balance Due S �n <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed gray%ng changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />Phone <br />1. All calls for inspection shall be made 24 hrs. In adv&nce • phone 259.881 5. <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 Service 48 hrs, before you dig. TOLL FREE NUMBER 1.800-424.5555. <br />y, .1.�F�e�E��.9y eueB - cuT LOC.>'re•.v /n•� T.vE sn� aocE cac <br />Tit/E Lo To BE .PErno✓ED /Jn/O Ik"EPLIDCEO Weir! <br />Free /1Eilrii'T CC.AW It GU�-C <br />S" NE�x/ r7,�irrF+.rAy 70 BE 2AIS7,946E0 �' Circe ST.9�/D o e0 <br />3'rewee 97oUT or-ev,*-7 VCCESS S11eV,1W ON ,OLUT <br />6, il9417- To Posr GGGHHir�v dTer_e <br />F ST1EE7 .PEco ✓STpr✓enan%<� Soo <br />7 j.1S4 SGYL-CEmENT /a,,z ;V- 7r2C✓ <br />((rflDE.e � ST.e�Fr /� Sae.£ G.s.aL,.,7�/,fOC'f rEly-9yiS'6� l..47A /�L�'OC <br />Approved for Consir lion ' Date <br />FINAL INSPtOTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />Everett, WA 98701 <br />Phone: 259-J815 <br />z <br />0 <br />CO) <br />0 <br />an <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned 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 replace public property damaged thereby. <br />Sigriature of Applicant Dato <br />WORK AUTHORIZED EVTHIS PERMIT MUST BE STARTED WITHIN <br />180 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 />