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Date % � ✓ � <br />Ap;�lication For <br />PU�f�IC i�J�ORKS PEI�MI � <br />Print or T)�pe Only <br />Applicant <br />Describe Proposed Wa'• <br />Project Address (if known) <br />qdare;s <br />Address <br />.4ttach lour (4) copies ol plans for proposed work - Draw to scale <br />• Property Lmes <br />• Outline and dimensions of all existing and <br />proposed 5tructures on Ihe lot <br />• Exis�in� and pr�posed utili�ies <br />Approved lor <br />Pu�L<\YorksPnrrytrY — <br />BttlB. Deo�. a � 1 l <r- __ <br />Publit Works feo � <br />Tolol Fea <br />lessApP�FeePa�d $ — <br />eaiance o00 5 . <br />C� <br />up rnone <br />note the fcllowinc7 as applica6la: <br />• Centerline of sVeet <br />• Indicate �'orih <br />• Shav any proposed grading chan�es <br />e Show measurements <br />LI <br />PERMIT CONDITIONS <br />1. A.!i calls for inspectlon shall be made 24 hrs. in advance - phone 259-8810. <br />1. All work shall be pedormed in accordsnce with this permit and current Ciry ot Everett Design and Construclion <br />Standards and Specifications. <br />3. Call Location Underground Service 4� hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />i�1C� V�C�U�'�`� � <br />C?'`�; i��8 s <br />/� <br />Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everelt PUBLIC WORKS DEPARTMENT <br />� 3200CedarStreet <br />Everelt, WA 96201 <br />Phone: 259•88t0 <br />ACKNOWLEOGEMENT OF CONDITIONS <br />� <br />0 <br />� <br />Q� <br />a <br />The undersi9ned o�vner/applicant hereby agrees ;o hold and save harm� <br />less the City ol Everelt Irom any and all claims for damages, costs. <br />expenses, or causes of aclion that may arise because ol installation <br />and mamtenance of the improvement or other ri�hl-oFway use hereto <br />applied tor and luriher a�rees to remove same upon noGce irom the <br />Cily and to replace public property dama�ed Ihereby. <br />Signature ol Applicant Dale <br />WORK HUTHORIZED BY THIS PERMIT MUST BC- STARTED WITHIN <br />180 DAYS OF DATE PEFMIT IS ISSUED 4ND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED 70 COMPIETION. THIS PERMIT MAY BE <br />CANCELLED 8Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />