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Date 1 a <br />Applicah�,i For � <br />PUi3LIC WORKS PERMIT <br />Print or Type Only <br />Public V�o�ks Pormll � <br />eiae. oao�.. �/ 7 ���___ <br />Pu�liC Work9 Fea <br />Total Fea $ <br />Less Appl Fee Paia $ <br />Balance Duo $ <br />��rcN)�u� + fl�m^r 9 ��7_5 -�:�LaL,�p,�'G .C'n�>f�_GvA 9�//S 5a>-a� <br />Owner Mailing Address City Zip Phone <br />� <br />Applicant <br />Mailing <br />Gity <br />Describe Proposed Work 7�Ip�11� ���(1./�hVP.i11 F✓1 /� ///uY'F �__ <br />Project Address (if kno•.vn) <br />Attach four (4) copies of plans fer proposed work • Draw to scale and note the following as applicable: <br />• Proper�y Lines <br />• Outline and dimensions of all existing and <br />proposed struclures on ihe lot <br />• Existlng and proposed utilities � <br />• Ce�terline ol street <br />• Indicat� No;th <br />• Sliow eny proposed grading changes <br />• Sho�v measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-881 :i. <br />2. All work shall be performeA in accordance wilh this permit and currenl City ot everetl Design and Const:uction <br />Standarils and Specifications. <br />3. Call Localion Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />P�a�,c. w�,pXS PEi2ir�ir �tYOT ,�'�cdUif', EO <br />Approved lor Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMEWT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />//2 2/ $ 7 <br />C ��"" <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />les; ihe City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />antl maintenance of the improvement or other right-ohway use h?reto <br />applied tor and furlher agrees to remove same upon nolice from the <br />City and to replaco public property damaged there6y. <br />Signature of Applicant Da1= <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEAEP.FTEfi IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITV UFON ANY STOPPAGE OF VJORK ON THIS <br />PROJECT OVER 90 DAYS :iJRATION. <br />