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Date�`�� <br />Applicalion For <br />PUBLIC WORKS �ERN11T <br />Print or Type Only <br />sz� ; <br />oW�a� <br />iJo r� <br />.v �_ �s <br />' PublicV.�i�i\aPermlla <br />IBItlB� DoO�� r � <br />raonc wo,ks <br />Tolal Foa <br />Lass qonl Fa <br />�L7 <br />"f `' .S<<: f � lc Y� S/,S".a` <br />cny <br />ui��� <br />Dnscdbe Proposed Work —�: �,4 ��. I! ,� i C�c �C u, 1- (� �,,.'�-�-� �`'. ,�('>'F J��'� j �i r� �� . 1 <br />Pioject Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note ihe lollowing as applicable: <br />• Property Lines • Centerline ol sVaet <br />• Outline and dimensions of all existing and • Indicate North <br />proposed sirucWres on ihe lot • Show any nroposed grading changes <br />• Existing and proposed utilities • Show measuremenls <br />PEFMIT CONDITIONS <br />1. All calls for inspection shaG bo made 24 hrs. In advance • phone 259•881 5. <br />2. All wo�k shall be performetl in accordance with this permit and current City of Everett Design and Conslruction <br />Standards and Specilications. <br />3. Call Localion U�derground Sen�ico 48 hrs. before you dig. TOLL FREE NUMBEF 1•800•424•5555. <br />�\ b <br />Approved for Conslruction Oate <br />FINAL INSPECTION Date <br />Approved as Coiisiructed <br />e�ere[t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 99201 <br />Phone: 259•8815 <br />� <br />ACKNOWIEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />Z <br />� <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />les:� the Cily ol Everett from any and all claims for damages, costs, <br />expenses, or causes ol action tliat may arise because of installation <br />and maintenance of !he improvement or olher righbohway use hereto <br />applied for and lurther agrees to remove s�me upon nolice irom lhe <br />Cily and to replace public property damaged Ihereby. <br />Sipnature ol Applicanl Date <br />N'ORK AUTHORIZED BY THIS PERMIT MUST 8E STARTED WITHIN <br />130 DAYS OF DATE PEflMITIS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8E <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS � <br />PROJECT OVER 90 DAYS DURATIUN. .- <br />'! <br />�!1 <br />� <br />