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Date / Y � I <br />Application For <br />PUBL�C WORKS P�RIUiI�' <br />Print or Type Only <br />ciiv ap <br />r�eo�wo�k-rc�n�li' — <br />Vj� -� <br />Bt�9.UcPL+ � <br />PublicWorksFce S <br />Totaliee <br />Luss AppL Fee Paltl S <br />Balance Duo S <br />Mailing Address City Zip Fnone <br />Applir.ant �, „ . <br />Descrihe Proposed Work <br />Project Atldress (il known) <br />Attach lour (4) copies oi plans 'or proposed wodc - Draw to scale and no�tfie following as applicable: <br />• Property lines .• Certerline ol st�eet <br />• Outline and dimensions of all existing and i Indic:�le North <br />proposed structures on the lot • Show any proposed gradinc� changes <br />• Existin9 and propos=d utilities • Show measurements <br />PERMIf CONDITIONS ' <br />1. All calls br irspec�ion shall be made 24 hrs. in advance - phone 259•881 5. <br />�. All woik shall be performed in accordance with this permit and current Ciry ot Everett Design and Construction <br />,�',tanda�ds and Specifications. <br />3. Call Loc�lian Underground Service �:8 hrs. before you dig. TOLL FREE NUMBER 1•SOO•424•5555. <br />C�� �'' `��� • � /� c,�-��- S�S r�`� <br />� ;�.�. / / <br />Approved for Construction Date <br />FINAL INSPECTION <br />Approved as Constrocted <br />evere[t PUBuC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA �8201 <br />Plione: 259-8815 <br />Da�e <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />�w <br />_ / <br />� <br />0 <br />� <br />� <br />0 <br />� <br />The undersigned own?r/applicanl hereby agrees fo hold and save harm� <br />less the City of Everelt Irom any and all claims for damages, costs, <br />expenses. or causes of action that may arise because of installation <br />and maintenance nt the improvement or other ri�ht-of�way use nereto <br />applied for and further agrees fo ramove same upon notice from the <br />Ciry and to replace public property damaged thereby. <br />SignaWre ol AGP������ Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED 'NITHIN <br />780 DAYS OF DATE PEAMIT IS ISSUED AND THEREAFTER IS TO <br />8E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />GANCELLED BY THE CIl'Y UPON ANY STOPPAGE OF WURK ON THIS <br />PROJECT OVER 90 DA'i S DURATIUN. <br />