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Date�� G <br />Applicatlon for <br />PUBLIG WORKS PEF�MIT <br />Print cr Type Only <br />� �r3o a <br />Address <br />JQ {M.i <br />Applicant PAailing Address <br />Oescribe Proposed Work �na���_-{!} �,��!�?�s�-!1� <br />Project Address (il known) <br />Lp <br />Zip <br />Bltlp Dap�rk' Pormi�,�_�r—�r � <br />O <br />Publlo Narks Foo <br />To�.IFee g <br />Loss AOP� Foa PeIJ $ <br />BalanceDue a <br />Allach four (4) copies ot plans for proposed work - Draw to sca'�; and note lheYollowing as applicable: <br />• Property Lir.=S • Centerline of street <br />i Outline and dimensions ol all existing and • �ndicate Nurih <br />proposed sUuctures onthelot • Show any proposed grad6ig change: <br />• Existing and proposed ulilities • Show measuremenls <br />PERMiT CONDITIONS <br />Phone <br />Phone <br />All calls for inspectiorz shall be made 2� hrs. in advance - phone 259•881 5. <br />All work shall be performed in accorda ice with !his permit and current Cif� of Everett Design and Constru:tion <br />Standartls and Speci�ications. <br />Call Location Underground Service 48 hrs. before you dig. TO! L FREE NUMBEii 1-Rr0-424•555.�i. <br />�l <br />Approved for' <br />�`c�2fn / T �.�T <br />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259�8815 <br />K �.i) U/.E'�'L <br />�����e�G <br />'- �,/� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />0 <br />♦�A <br />V♦ <br />O^ <br />1� <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />— less the City of Everett from any and all claims lor damages, costs, <br />expenses, or causes of action lhal may arise because o( installation <br />and mainlenance of the improvement or olher ric�ht•of-way use hereto <br />applied for and turther agrees to remove same cP�n notice trom the <br />Date Ciry and �o replace public property damaged thereby. <br />Da�e <br />Signature of Applicant Date <br />WORK AUTHORIZED BY ThIIS PERM1IIT MUST BE STARTED WITHIN <br />180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE OILIGENTLY PUFSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />