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Date—*Lo <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />Describe Proposed Work <br />Project Address (if known) <br />Public Worts Perm" <br />.e' <br />BI00 Depr. <br />Public Works Fee <br />Tote$ Fee $ — <br />Less APPI. Fee Paid S <br />saleece Due <br />Phone <br />City Zip Phone <br />Attach four (4) copies of plans for proposed work - Drew 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 grading changes <br />• Existing and proposed utilities • Show measurements <br />IIiS <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Constrl,otion <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />Approved for Construction Date <br />isssssssss�e <br />z <br />O <br />O <br />a <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 to replace public property damaged thereby. <br />FINAL INSPECTION Date Date <br />Approved as Constructed Signature of Applicant <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />everett PUBLIC WCRKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />Everett, WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />Phone: 259-8815 PROJECT OVER 90 DAYS DURATION. <br />