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Date��D <br />Application For <br />PUBLIC WORKS PERMIT <br />Print orType Only <br />Mailing <br />'G �— <br />Applicont <br />Describe Proposed Work <br />Prn�ect Addiess �if known) �2, <br />HadrCss <br />2ip <br />Attach lour �4) copies of plans lor propo,etl work - Draw !o scale and note ihc followinq as aoo:icahln� <br />• Propern� Lines <br />• OuNine anti Aimensions ol all existing and <br />proposed s�ruciwes on the lot <br />,� • E■isting and pro�:esed utilities <br />Approved <br />' IJ <br />�• �, � <br />Publ¢ Worke Parm�t • � � �% � <br />BIaB Oeo�� • <br />�ot�im worky Fee — <br />Toiei Fee $ <br />ll54Appl. fpe PeiC $ <br />8ala�ce Due S �� ���— <br />• Genterline of street <br />• Indicate North <br />• Show any pruposed gratlinc� chan�es <br />• Show measurement; <br />PERMITCONDITION5 <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pednrmed in accorJance with this permit and current Cily ol Everett Design and Con�truction <br />Standards and Speciticalions. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER !-800-424•5555. <br />RNAL INSPECTI6N.�" - � <br />Approvetl as Construded <br />evemU PUBUC WORKSDEPARTMENT <br />� 3200 Cetlar Sireet <br />Everelt, WA 98201 <br />Phor,c: 259�8810 <br />Oa�e <br />ACKNOIC'LEDG[MEMT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />O <br />a <br />Th� undersinnr.d owner,�appticant hereby aorees to hold and save harm- <br />less Ihe Clly ol f=vere�! Irom any and all c�.�aims loi damaqes, costs, <br />ezpr:nses, or causes of adion �hal may arise because ol installal;on <br />anA maintenance of ihe improvement or othr,r nght-ol�way use hereto <br />applied lor and lurther agrees to remove same upon nolice from the <br />City and to replacr: publir, property damaged thereby. <br />' , ��b .Y <br />��, ,� ���< <� � <br />• Signature ul Applicant ' Date <br />�VORK AUTHORI2[D BV 7HIS PERMIT MUST BE STAFfCD WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUE:D AND THEREAFTER IS TG <br />PE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8E <br />CANCBLLED BV THE CITY UFON ANY STOPPAG[ OF 1NORK ON THIS <br />PRUJECT OVER 90 DAYS DUI7A?ION. <br />