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,-� r <br /> �n �ublic Woiks Permit I <br /> Date rC) �? O /a�F� <br /> BIaB�Oepf.• <br /> Applicetion For <br /> PUBLIC WORKS PERMIT PuElicWorkaFee <br /> Total Fee s <br /> LessAoO�-FeePaid s <br /> Balance Ouu s <br /> Print or Type Only <br /> '�' N � 8G"'o cJ �o� �7/6 l��u.ou�— <br /> � f��21/�-� � r 7 Phone <br /> Owner Maixng Haaresa •� <br /> qpplicant Mailing Address City Zip Phone <br /> ��� �Q�ti�,� <br /> Deacribe Proposed Work <br /> W <br /> Project Address(it known) � � � <br /> Attech four(4)copies �f plans for proposed work� Draw to scale and note the following as applica6le: �- <br /> � PropertY Lines � Centerline of street � <br /> • Outline end dimensions of all existing and • Indicete North <br /> proposed structuras on the lot • Show any proposed grading changes <br /> • ExlstinB and proposed util;ties • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> 1.All calls for inspection ahall be made 24 hrs.in advance-phone 259•SS10. <br /> 2.All work shall be performed In eccordance with this permit and current City of Everetl Design and Construction <br /> Stendards a�d Specifications. � <br /> 3.Call Location Underground Service 48 hrs.before you dig.T6LL FREE NUMBER 1-800�4245555. <br /> j� � O <br /> ��'��ctiv� �s-7'�.�lz�, <br /> TiiS/��/''o�� � <br /> � <br /> O <br /> � a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees;o hold and save harm• � <br /> less the City of Everett from any and all claims for damages, costs. <br /> ezpenses, 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 /> Approved for Construction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION Date Date <br /> Approved as Constructed Signatuie o(Applicant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PER!.ifi �S ISSUED AND THEREAFTER IS TO <br /> � 3200CederStreet BE DILIGENTLY PURSUE:D TO Cl.`MPLETION.THIS PERMIi MAY BE <br /> Everett,WA 98201 CANCELLED BY THE CITI UPON A�Y STOPPAGE OF WORK ON THIS <br /> Phone:259-8870 PROJECT OVER 90 DAYS DURATION. <br />