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Date�_� <br />Application For <br />PIJBLI�� WORKS PERMIT <br />Print or Type Only <br />Applicant <br />Addres5 <br />Mailing Address <br />Describe Proposed Work TN�,�I f� � I i�%�m �'r(�%l� C 1 <br />Project Aodress lil known) <br />City <br />Pu�im Worka Permi� • <br />BiaO. Depl. r � _ <br />1'eeuc worb vee — <br />Totel Fee S _ <br />Lesf AppL Fee PeiC S <br />Belecca Due <br />Zip Phone <br />Attach four (4) copies of plans }or proposed work - D�aw to scale and note Ihe lollowin� as applicable: <br />• Properly Lines • Centerline of street <br />• Outline and dimensions ol all existing and • Intlica�e North <br />preposed siructures on lhu lot • Show any proposed grading changes <br />• Existing and pnposed Wilities • Show measurements <br />P[RMIT CONDITIONS <br />7. All calls for inspeclion shall be made _'J hrs. in advance • phone 259•881 S. <br />2. All work shall be performed in accordance with this perm,t and current City of Everett Design and Construction <br />Standards and Specitica'ions. <br />3. Call Location Ur.Aarground Service 4d hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />j'�(�c�Y�.t, Lf%�z�2� �F2szt ,� /L�T ���t�11?c7� �/.i/B% <br />� <br />�%,,� <br />Appro�•ed for Construction Date <br />fINAL INSPECTION Oale <br />Appfoved as Cons�ruC�ed <br />everMt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259-8815 <br />ACKNOWLEDGE�dENT OP CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />�' <br />%� <br />,O <br />a <br />The undersigned otvner/applicant hereby agrees �o ho".J and save harm• <br />less ihe City uf Everett lrom any and all claims Icr damages, costc, <br />expenses, or causes of action lhaf may arise becausa cl installaiion <br />and maintenance of the improvemenl or other right-of-way use herelo <br />applied for and lurther agrees to remove same npon n.Nice irom Ihe <br />City and to replace public property damaged thereby. <br />Signature ol Applicant Date <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED 1M1'ITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND TfIEREAFTER IS TO <br />BE DILIGE4TLY FUFSUED TO COMPLETION. TH�S PERMIT MAY �E <br />CANCELLED BV THE qTY UPON ANY S10PPAGF. OF WORK ON THIS <br />PROJECT OVER 9G DAYS DURATION. <br />