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Date wIE(v <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />i' Mf. < j,7y' <br />Owner Mailina AddrLess <br />Applicant <br />Address <br />©o�-3s2-3�o _coo /7 /J�q•�'� <br />Public Work:Pe, • <br />Bide. Dept a <br />F tfr�i <br />Pu"" Worb Fee <br />Tobl Fee S �y <br />Leta Appt Fee Paid $ <br />Balance Due $ '—�VC. ATE <br />7A <br />�)U r/ _)l y <br />City Zip Phone <br />City Zip Phone <br />Describe Proposed Work /11S i - e1 A °-lx-t-fiu,' t— V( <br />i V <br />- <br />Project Address (if known) _ /S r v - -Y*'-- WUJ <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 grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE O <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrsin advance - 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 />;V �J'�,9irJ/9GE rvrcC con�T.Fo��� o.,,Lci; <br />- 0 <br />W <br />FINAL INSPI <br />Approved as <br />i <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />0— <br />Date <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 />appfied for and further agrees to remove same upon notice from the <br />City anj,�plac2,plqQc pr2glirty da*gW thereby. <br />M <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS 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 />