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`�3 <br />Date <br />Public Works Permit L ,. <br />0 Application For - <br />Bldg. Dept.a <br />PUB0qICt WORKS PERMIT <br />Pub <br />Toul FeeFef $ <br />O <br />- <br />Less Acpt Fee Paid $ <br />Balance $ <br />LJ <br />Print or Type Only <br />Due <br />IA 7CS 60 SD. 101,K <br />ST. 2f1 Till ld q 9�Ia <br />Owner o�� mr Mailing Address City <br />Zip Phone RA� <br />F <br />AS:D d3 So <br />WA JA&w <br />Applicant Mailing Address City <br />Zip Phone <br />DescribeProposed Workr eZe1M JxZrr %r�6 l/ ss • A-1ln <br />=5k/ MKA9�Z <br />&L'1Z r <br />W. <br />N 1 1 f 4 7.A<'nl , I24 T ��1. M �ti ee 7 <br />Project Address (if known) � <br />GV r1 SH'i <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />filiIiiiiiiiiii <br />• Property Lines • Centerline of street <br />• Outline and,dimensions of all existing and O Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />p�X.} <br />DO NOT WRITE BELOW THIS LINE <br />' <br />O <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 O. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424.5555. <br />z <br />Ch <br />O <br />Apprgv)�(or G ns�uc(on Date <br />i <br />FINAL INSPECTION Date <br />Approved as Constructed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, 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 foraad,further agreeg�fo remove same upon notice from the <br />City and io replake public pryperty damaged thereby. I- , <br />WC,R AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 AYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />B 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 />