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t <br />Date I =P `�O 10) 004 <br />Apphcatlou For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Ulry zip <br />Public Works par d a <br />Bldg Depl. <br />Public Works Fee <br />Total Fee <br />Lee, appt Fee Paid i <br />Balance Due <br />Applicant Melling Address City Zip Phone <br />Describe Proposed Work <br />Project Address (if known) <br />Attach four (4) copies of plane for proposed work - Uraw 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 />PERMIT CONDITIONS <br />I. All calls for Inspection shall be made 24 hrs. In advance • phone 259-8810. <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 hra before you dig. TOLL FREE NUMBER 1-500-424.8888. <br />Approved for Construction <br />NI17 PSI iL—��Lf�'1 I <br />►m C ices_ <br />Z/U /jC) <br />Datr. <br />FINAL INSFaCTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />Everett WA 98201 <br />Phone: 259-8810 <br />2(5Q' <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />O <br />z <br />O <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City or 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 />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 C11 y UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVEP 90 DAYS DURATION. <br />