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Date <br />rn <br />PI�BLIC <br />i� <br />Ci <br />c <br />Print or Type Only �:� <br />Pd <br />� ��.. <br />�1�� V" '� �'L ��`,'� <br />oW�e� a� � <br />c:i ` <br />� �IA-kL °�s2.� ti <br />' ApplicaM <br />Application For <br />W�RKS PERMIT <br />o i-; <br />r., n <br />��; ��; <br />�.. � <br />u+ <br />� <br />Mailing Address <br />�s <br />Pu011c Worka Permil r � !/CJ / <br />BIEp. Dept. a <br />PublicWorksFee s �.^' <br />Tot01 Fee �� <br />Leaa ADP�. Fee Peid S� <br />BelancaDua S �s <br />1�7/.� � ` <br />a�v <br />o3c <br />City Zip Phone <br />Describe Proposed Work � �� � � �� � ���R' `l° u Z. 7 � /f� <br />Project Address (rf known) � <br />Attech four (4) copies of Ulans for proposed work • Draw to scale and note ihe following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existirg and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />• Centerline of stree[ <br />• indicata North <br />• Show any proposed gr�ding changes <br />• Show mezsurements <br />PERMITCONDITIONS <br />1. All calls for Inspection shell be mede 24 hrs. in advance • phone 259•8810. <br />2. All work shall be performed in acco!dance with this permit and current City of Everett Design and Construction <br />Standards e�d Specif(cations. <br />3. Call Locetion Underground Service 4B hrs. before you dig. TOIL FREIc NUAABER 1•B00-4245555. <br />�• �✓'a5��-�-- � c�;� �rd C �-� C � � <br />Approvetl as Gonstruccea <br />�I� PUBLIC WORKS DEPARTMENT <br />y3200 Cedar Street <br />� Everet4 WA 98201 <br />Phone: 259•8810 <br />�n� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />0 <br />� <br />� <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everelt from any and all ciaims for damages, costs, <br />eapenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right•of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Y � .1" I (/6.-.�.. ,� U� l� /ly/�7/ <br />Sgndtu� re o�f APPlicant • �a�e <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />