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Date 12111Z n <br />Appllcr',ion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Work, Permit a <br />Bldg. Dept. e�%�l/�7 <br />Public World Fee <br />total pee <br />Less APPI Fee Paid <br />3alance Due $ <br />G `i3-11300 <br />inn <br />Phone <br />bg4iQ Aa b,lab <br />Applicant A4ailing Address City Zip Phone <br />Describe - . /llit►7frill///InP1ruNT(](v,f/t/1t1.7 Mfl# 7]IsaAsllisc%!/d �� <br />A .. a r <br />Project Address lif known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable <br />• Property Lines <br />• Centerline of street <br />• Outline and dimensions of all existing and <br />• Indicate North <br />proposed structures on the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />LINE <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8815. <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. before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />evere[t PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett. WA 98201 <br />Phone: 259.8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />rid <br />M <br />O <br />n <br />r� <br />0 <br />a. <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City nd to replace public progerty damaged thereby. <br />X <br />Signalture of Applicant v Date <br />WORK AUTHORIZED BY THIS PERMIT UST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CA.ICELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />