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r <br />Date�� ( <br />�1 <br />Application For <br />P�'BLIC WORKS PERMIT <br />Print or Type Only <br />df �:��Y � <br />���Y <br />PUEIic Worka Permlt a �/ �-L� <br />BItl9. DePI. • � C � ��v , � <br />p�ero wo�xs Fea $ <br />TalalFoo <br />Less AOP� Fee Paitl $ <br />B�iance Due $ <br />a y ���s= � y� <br />� 'f� Z�p Phone <br />Applicant Mailing Address City <br />i / <br />Describe ProPosed Work � �%� � 7 L x t� �`��� <br />Project Address (if kno�.vn) � " '�— <br />Attach four (4) copies of plans for proposed work • Draw to scale and note � Ceniteµrline of sheeii able: <br />• Property Lines • Indicate North <br />• Outline anA dimensions ot all existing and � Show any proposed grading changes <br />proposed struc;ures on the lol � Show measurements <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />1. All calls tor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be pertormed in accordance wilh this permit and current City of Everett Design and Construction <br />Stendards and Specifications. <br />3. Call Localion Unoerground Servi�e 48 hrs. before you dig. TULL FREE NUMBER 1•800•424•5555. <br />qpproved for Conslruction Date <br />FINAL INSPECTION Date <br />Ppproved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl, N1A 98201 <br />Phone: 259-8815 <br />r�'S �rv <br />/� s�U <br />� <br />� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />�w <br />s i <br />� <br />0 <br />� <br />� <br />0 <br />a <br />The undersigned owner/applicant hereby agrees to hold and save costs, <br />less the Ciry of �Everett from :my and all claims tor damages, <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 for and (uriher agrees to remove same upon notice irom the <br />Ci!y and to replace public prop=rty damaged thereby. <br />Signature ot Applicant Date <br />WORK AUTHORIZED BY THIfi 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 WOAK ON THIS <br />PROJECT OVER 90 DAYS DURATION. � <br />� <br />