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f. --- --- . _ _ <br />- ; QG, .-. <br />Date,� _ <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Describe Proposed Work <br />Proiect Address Iif known� <br />��.L <br />Maiiing <br />Address <br />�� r <br />8 <br />�7 <br />PuOhe Works Pefrm;il • �—�— <br />e�ae oroi.. 7(Z .�,%�/ ��% % <br />i <br />Puolrc Works Fee <br />Total iee $ <br />Lesa Appl i�e Pa�tl S <br />Beianca0�e S <br />� <br />2ip <br />5�� /'/WV � �Y/1i71.004 /OG <br />C��Y � Z� Phone <br />Attach lour 141 co�ies of plans br proposed work - Draw lo scale anA nole Ihe Icllowing as applicable: <br />• Property Lines • Centerline of streel <br />� • Outline and dimensions of all ezisting and • Indiwle North <br />proposed structures on Ihe lol A Show any proposed grading changes <br />..,+ • Exlsting and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shail be made 24 hrs. in advance • phone 259•$870. <br />2. All work shall be peAormed in accordance with this permit and current Cily of Everett D=sign and Construdion <br />Standards and Specifications. <br />3. Call Location Undergrcund Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424-5555. <br />� �- <br />Li�I��� - l - � �� <br />ii�., <br />� <br />Approved lor Const <br />,��� �r ��� ` <br />FINAL INSPECiION Date <br />Appreved as Constructed <br />rverelt PUBLIC WORKS DEPA(iTtdENT <br />� 3200 Cedar Street <br />Everett, WA 9820t <br />Phone:259-8810 <br />r i <br />%� r.C.,au.�{�� �� <br /><" <br />•�fc: �'��r_.f`; <br />j� / %D <br />W <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />ACKNJWLEDGflM8N7 OF CONDITIONS <br />The unde�signed owner/applicaM hereby a�rees to hold and save harm- <br />less Ihe City ol Everett Irom any and ail claims lor damaqes, cosls. <br />expenses, or causes of action Ihat may arise because of installa�ion <br />and mainlenance ol ihe improvemenl or other nght-of-way �se hereto <br />applied lor and furiher aqiees to remove same upon notice Irom the <br />Ci�y and �o rep�ace pubhc p�ope�iy damaged th�reby. <br />Signalure of Applicanl Date <br />WORK AUTHGR12ED BV iHIS PEFMIT MUSi BE STARTED WITHIN <br />180 DAYS OF DAT[ PERMIT IS ISSUED AN� THEREAI"TER IS TO <br />DE DILIGENTLY PURSUEU TO COMPLETION. THIS PERMIT MAY BE <br />CANCfLLED BY THE CITY UPON ANY STOPPAG[ OF WORK ON THIS <br />PROJECT OVER 90 DhYS DURATION. <br />