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Date �� 6 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Address <br />Malling Aatlress <br />f. <br />Zip <br />Puni¢ Wur�a Permp • �� ��/ <br />eioc oeo�.. � — ����5� <br />PuCbc Worwe Fae s <br />1ota1 Fea <br />LnnApplFeeG�iC S <br />2O o0 <br />BabnceDue S „__ <br />Phone <br />Describe Proposed Work �OtiSTi2UCT S.�iC�. _ <br />Prolect Address (if known) �v/�= / — <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the Iollowi��g as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions ol all existing and • Indicale Norih <br />proposed structur?s on the Iol • Show any proposed grading chan�es <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. 1111 calls for inspeclion shall be made 24 hrs. in advance - phone 259•8$� b. <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 hrs. belore you dig. TOLL FqEE NUMBER 1•800•424-5555. <br />y��y� ���e �U,�-�� �,�� 5.����,�u-. <br />i.s�E f�.��c,c-�,�2�r ��v.9<<r .6�� ,c��.��c�v <br />/,J�;o�i ��,,y1.�T <br />Approved as Construct d <br />everett PUBLIC KS 0 <br />� 3200 Cedar Streel <br />Everelt, WA 98201 <br />Phone: 259-BB7 5 <br />� �(5�� � <br />Date <br />A NT <br />„yve':....r•�.. <br />l�Ain/,'G�'1� �'y <br />bf/ T�rE <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />� <br />�� <br />� <br />� <br />L J <br />� <br />� <br />O <br />a <br />The undersigned owner/applicaM hereby a8rees to hold and save harm- <br />less the City ol Everett Irom any and all claims for damages, costs, <br />expenses, or causes of action lhat may arise because ol installation <br />and maiMenance ol Ihe improvement or other right-ol-way use hereto <br />applied lor and lurther agrees to remove same upon notice Irom ihe <br />City and to replace pu6lic property damaged thereby. <br />,,�.�� � i��� <br />nalure of Applicant Date <br />WORK AUTHORIZF.D BY THIS PERM�T MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br />BE DILIGENTLY PURSUED TO COtv1PLETION. THIS PEHMIT MAV BE <br />CANCELLE; BY THE CITY UPON ANV STOPPFGE OF WORK ON THIS <br />P�iOJErT OVER 90 DAYS DURA710N. <br />