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Date�s� � <br />Application For <br />PU��IC WORKS P�RMIT <br />Print or Type Only <br />oZ% ���u � p�, rOP �.1�, �ic�� <br />Mailing Address Ciry <br />� �3�ZZ /�t s <br />Mailing Address City <br />Zip <br />Pu01ic Yfarks Perm� 1 a_ / r1 <br />Bltlg. DePI. s — rl� / !'/�j`�A � <br />,TT� <br />PubliC Works Fea <br />Total Feo S <br />Less AO�� Feo Paitl S <br />BNanro Uuo $ <br />Phone <br />a�l�- <br />Projcot Addres� (if known) <br />Auach four (4� copies of plans for proposed work • Draw to scale and note <br />• ?roperty Lines . <br />• Outline and dimensions of all existing and <br />proposed struclures on the lot <br />• 'cxisting and proposed utililies <br />Appfoved for <br />PERMIT CONDITIONS <br />following as applicable: <br />• Centerline oF streel <br />• Indicate Morth <br />Y Show any proposed grading changes <br />• Show measuremenis <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All work she!I be performed in accordance with this permit and current City of Fverett Design and Construction <br />Standards and Specifications. <br />3. Call Localion Underground Service 48 hrs. befa you d��. TOLL FREE NUMBER 1•800-424-5555. <br />p a'�iC << <;,-��s <br />ruction <br />,lZ�n-;�i /�/'�T /'�dGr.'c%I <br />Date <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98207 <br />Phone: 259�8875 <br />� Gj'g /� <br />�_�; =� <br />ACKNOINLEDGEMENT OF CONDITIONS <br />W <br />H <br />s <br />� / <br />�� <br />� <br />� <br />�� <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everatt from any and all claims for damages, costs, <br />expenses, or causes of action thal may arise because of installalion <br />and maintenance of Ihe improvement or other right-ot-way use hereto <br />applied for a�d further agrees to remove same upon notice from �he <br />City and to replace puhlic property damaged thereby. <br />Signature of Appiicam Date <br />WORK AUTHORIZEU Bl' THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATL- PLRMIT IS ISSUED AND THEREAFTER IS TO <br />B[ DILIGENTLY PURSUED TG COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CIT'! UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVCR 90 DAY: DURATION. <br />