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Date�L(1 PubLc Work6 Pev <br /> Application For eiae oeo� ������_ <br /> PUBLIC WORKS PERMiT °°°°°W°,�sF�� - <br /> Talxl Fee s <br /> LessAon� !ee PaiO �_ <br /> eaience Uua S_ <br /> Print or Type Only — <br /> �`��t��l l ���� I �� �—It�� �f�lq-j,T f .�—1'�� <br /> Owner Mailing Address City Zip Phone <br /> ,�7'',l�'l�, _ <br /> Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work ����� �I i � �� <br /> W <br /> Pro�ect AAdress�il known) � <br /> Atlach four(4)copies of plans for proposed work• Draw to scale nole ihe tollowing as applicable: � <br /> • Property Lines • Centerline oi sireet � <br /> • Outline and dimensions ol all existing and • Indicate North <br /> proposed structures on thE lot • Show any proposed gradinc�chanc�es <br /> • Eaisting and proposed utilities • Show measuremenis � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection sball be made 24 hrs.in advance-phone 259•8810. � <br /> 2.AI�work shall be pedormed in accordance with Ihis permil and current City ol Everett Design and Construction <br /> Standards and Specitications. <br /> 3.Call Location Underground Service 48 h�s.belore you dig.TOLL FREE NUMBER 1•800-424•5555. � <br /> (1Cfi �L~�11�2�C� /.r��B <br /> � � <br /> �� � <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIGNS <br /> The undersigned owner/applicant hereby agrees to ho!d and save ha�m� <br /> less ihe City of EvereU Irom any and all claims for damages. cnsis, <br /> ezpenses, or causes ot action thal may arise because ol installation <br /> and main�enance of lhe improvement or olher nght�of�way use hemto <br /> applied lor and lurther agrees to remove same upon notice Irom ihe <br /> Approved lor Construqion Date Gity and to replaCe public propeiry damaged iheic6y. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signa�u e of Appli[ant Date <br /> evemtt PUBLICWORKSDEPARTIdEVT WORK �UTHORIZED BY THIS PERMIT A1UST BE STARTED WITHIN <br /> � 3200CederSireel 180 DAYS OF DATE PERMIT IS ISSUEO AND THEREAFTCR IS 70 <br /> EveretL WA 98201 BE D�LIGENTLV PUFSUED i0 COMPLETION. THIS PERMIT fJ�AV BE <br /> Phona 259-8810 CANCELL[D BY THE CITY UPON ANY STOPPAGE OF WOFiK ON THIS <br /> PROJECT OVGR 90 DAYS DURATION. <br />