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Date � ��! ' <br />� <br />Application For <br />PUBLIC WORKS PERIVIIT <br />Print or Type Only <br />`l ( 4�.1�7f i- - <br />Puebc Woixs Pcrmrt . <br />oiao oeot+ '�'i�T ��J� <br />Pu�llc Workn Feo <br />TateiFoo $ <br />Less AppL Fee PaiE S <br />Belence0ue $ <br />Zip Phone <br />�-. <br />pplican( Meiling Address Ciry Zip phone <br />Describe Proposed Work <br />Proiect Address (if known) <br />Attach four (4) copies of plens lor p�oposed wOrk - Draw to sCale and note Iha followiog as applicable: <br />• Properry Lines <br />• Outline and dimensions of all existinq and <br />proposed slructures on the lol <br />• Exis�ing and proposed utllilies <br />PEFMIT CONDITIONS <br />O Centerline ol street <br />• Indicale Norih <br />• Show nny proposed 9rading ch:3nges <br />• Show measurements <br />t. All calls tor inspection shail be mede 24 hrs. in advance - phnne 259•881 5. <br />2. All work shell be pertormed in accordance wilh this pe�m�t antl current City of Everott Design and Construction <br />Slandards and Specifir,ations. <br />3. Call Location Underqround Service 48 hrs. belore y�u dig. TOLL FREE NUMBEH 'I -800•424-5555. <br />��� J�f k`� � L 1,(��I�(� 7/y`4.= <br />1= Lt; � 1 i �� � �',Y� l ��l l `� I � �-� �' _� , <br />�� �,` .'�, <br />Approved lor Construclion <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />• <br />�"' <br />� <br />0 <br />a <br />The undersigned owne�/applicant hereby agrees lo hold and save hann- <br />— less ihe City of Everett Irom any and all claims for damages, costs. <br />expenses, or causes of action Ihat may arise bncausa ol instal�ation <br />and mainlenance of the improvemenl or other right-obway use herero <br />applied lor and further aqrees to remove same upon notice from the <br />Date City and to replece public property tlamaged thereby. <br />FINAI INSPECTION Dale <br />Approved as Constructed <br />everett PUBUC WORKS �EPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone: 259-8815 <br />4 <br />�A ' _ � .', .' ' . . <br />Q.. ' <br />� '�� � � <br />Signalure of Applicant Date <br />WORK AUTHORIZED BV THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTE� IS TO <br />BE D�LIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />