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Date�l•3�'fi <br />Application For <br />PUB�.IC WORKS PEF�iVdtT <br />Print ur Type Only <br />AppliCant <br />Cily Zip <br />Giry [ip <br />reni�cv;cr.snr.mn. _ <br />a�ae o�a�.. / 7.iS('J <br />Puouc wmrs Foa <br />Tolal foo $ <br />LessApp' FeePni� 5 <br />palance bue J <br />�� <br />Describe Proposed Work (_.Q�l(jN r ���=.t�1�✓1 I diaK• 'fri' ��A! i��r�P�/ <br />Pro�ect Address Of known) <br />Altach lour (41 copies ot plans lor proposed work - Draw to scale and note the tollowing as appliwhle: <br />• Property Lines <br />• Outline and dimensions ot all existing and <br />proposed stiuCtures on the �ot <br />• Existing and proposed u�illties <br />PERMIT CONDITIONS <br />O Cenlerline ol street <br />e Indicate Narih <br />O Show any propose�tgrading changes <br />w Show measurements <br />1. All calls lor inspection shall be made 24 hrs. in advance • pho^.a 259•881 5. <br />2. All work shall be performed in acr.orAance with this aerm��! aid current Ci!y of Everet! Cesi9n and Construclion <br />Staroards �nd Specilications. <br />3. Call Location Underground Service AA Y,rs. before y�u dig TOLL FREE NUMBER 1-800•42�b-55.55. <br />App'�ved lor Couslruclion <br />/ %c> <br />� G� r <br />,G ���'�'�� <br />����� � , <br />��� <br />L��' <br />Ar,KNOWL D EMENT OF CONDITIONS <br />��J <br />The undersiyned ownedapplican� herebyagreesto huld and save harm� <br />Iless �he City of Everett irom any and all claims for damages, costs, <br />expenses, or causes of action that may arise because ot installation <br />and maintenance ot lhe improvement or olher righFobway use herelo <br />appliad lor and lur(her agrees to remove same upon notice hom the <br />��'�" City and to replace public property damaged thereby. <br />FINAL INSPECTION Date <br />ApP�oved as Constructed <br />��•i.���� PUBLIC WORKS DEPARTMENT <br />� 5200 Cedar Slreet <br />Everett. WA 9�201 <br />Phone:259�8815 <br />Si9nature ol Applicant Date <br />WOIiK AUTHORIZEO BY THIS PERPAIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND T!'.EREAFTER IS TO <br />PE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />C.�MCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVEH 90 DAYS DURATION. <br />