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Date�'G� <br />Application For <br />PUBLIC VI/ORKS PERMIT <br />Print or Type Only <br />rnamng naaress <br />Describe Proposed Work <br />Prolect Address (if known) <br />Giry <br />F"''i <br />Publm Works Per 'I / _ <br />aiav�oop� . _ <br />PUE:ic Woil.f Fee $ <br />TOlal Fo� <br />Les9 AOOI Feo Pala $ <br />Bnlaaco Due <br />Attach lour (4) copies ol plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines � Centerline of street <br />• Outline and dimensions ol all exis�ing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />7. All call; for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All work shall be pertormed in accordance with this permit and current City ol Everett Design and Construclion <br />Standards and Specilications. <br />3. Call Location Under9round Service 48 hrs be(ore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />%,J.S'�;c WU,�S� ;i�,er•�-% �.�'>T ,<EC,�v;��c,� �'��/a 7 <br />...� /i <br />�--1f C�'.� <br />Approved tor Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Slreet <br />Everetl, WA 98207 <br />Phone: 259•d315 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />�J <br />The undersigned owner/applicant hereSy agrees lo hold and save harm- <br />less Ihe City of Everett Irom any and all claims for damages, costs, <br />expenses, or causes of action that may arise because ot instaltation <br />and maintenance of the improvement or othr, right-ol-way use .. �to <br />applied lor and further agrees to remove san�e upon notice Irom �he <br />City and to replace public property damaged thereby. <br />Signature of Applicant Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEP IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOflK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />