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� <br />Date� <br />� � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mailing Address <br />7 /V Sl ��- <br />Mailing Address <br />Describe Proposed WorY. �� NGNY- i_vLt c1/?T_�i/p.u.f s�,� <br />Prolect Address (if known) <br />PUEIic Y/o�ks Pormil • <br />BIOg. OepL + ��— <br />PubLc Works Feo S <br />Tolnl Fao <br />LessAppL Fce PaiO $ <br />Baiancc Due � <br />up rnone <br />Attach four (4) copies ot plans for proposed work - Draw to scale and note lhe following as applicable: <br />• Property Lines <br />• Outline and dimensions of all exisling and <br />proposed structures on Ihe lot <br />• Existing and oroposed u�ilities <br />• Centerline ot street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />Phone <br />PERMIT CONDITIUN� <br />t. All calls for inspr.ction shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be performed in accordance with this permit and current City of Everett Oesign and Construction <br />S!andards and Specifications. <br />3. Call Location Uncerground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />P��i.c G��• ��L� Nc9��v-,,.�� <br />Approved for Conslrudion Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone: 259•0810 <br />. '.j;s' <br />f �t� � <br />. n 1.'(, � �' . <br />]t/ . <br />/� /G -�8 <br />�� <br />ACKNOWLEDGEMENT OF CONUITIONS <br />� <br />� <br />� <br />a <br />"fhe undersigned owner/2pplicant hereby agrees to hold and save harm� <br />less the City of Everett Irom any and all claims for damages, costs. <br />expenses, or causes ol action that may arise because ol installation <br />and maintenance of ihe improvement or other righl�ohway use hereto <br />applied lor and lunher ac�rees lo remove same upon notice irom the <br />Ciry and to replace public pwperry dama�ed thereby. <br />SignaWre of Applicanl Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUEU TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CI7Y UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />