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� oate 7—a�y� <br />P.��'ication For <br />PUBLI� WORKS PERMIT <br />Print or Type Only <br />Owne� <br />���L. <br />[� <br />Zip <br />Puee< Wod� Permn • � �"�`J <br />BiEp. Dept • <br />vuerc work. ve. Q <br />iot�l Fee f � ` <br />Leas �oo� Fee PHE 5 <br />'/ P o <br />B���nce Due S ,�57 �— <br />� <br />Mailing <br />Descdbe P�oposed Work �OJo i'cf, J�/Jti�-Q,J^ �/GG <br />ProjPc� Addresa (il known) <br />Atlach fow (4) coples of plans for proposed work - Draw to scale and note the following as applicable: <br />� Property Lines • Centerline ol street <br />• Outline and dimensions ol all existing and • Indicate Norlh <br />proposed siructures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shell be pertormed in accordance with this permit and current Ci;y of Everetl Design and Construction <br />Standerds 3nd Specificatlone. <br />3. Call Location Underground Service 48 hrs. hefore you dig. TOLL FREE NUMBER 7-800•424•5555. <br />�4. P�►- ,S'G-/'r� a��o �-oda � <br />vr. 20 O c��'3 /!?�'�fir�lvrr-- <br />for <br />IJ <br />"pproved as Constructed <br />everett PUBLI:, WORKS DEPARTMENT <br />� 3200 ��edar Street <br />Evere�t. WA 98201 <br />Phone: 259-8815 <br />� <br />Date <br />� <br />U <br />♦�A <br />V♦ <br />0 <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersianed owner/apFlicant hereby agrees to hold and save harm- <br />less Ihe City o( Everett from any and all claims lor damages. costs, <br />expenses, or causes of action ihat may arise because ol installation <br />and maintenance ol the improvemen[ o� othet right-of-way use herelo <br />applied lor and lurther agrees to remove same upon nolice Irom the <br />City and to replace public op rty damaged Ihereby. <br />gnatu 1 A icant Date <br />WORK UTHORIZED BV THIS PERMIT MUST BE STAFTED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUEO AND TIIEREAFTER IS TO <br />BE DILIGENTLV PURSUED i�0 COMPLETION. THIS F�ERMIT MAY BE <br />CANGELLED BY TfiE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 5U DAYS DURATION. <br />L -� <br />� <br />� i <br />