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Date 3���� <br />Application For <br />PUBLI�C WORKS PERMIT <br />Print or Type Only <br />� <br />�, 1 I Nc: r is�i•�- <br />Describe Proposed Work <br />Piojecl Address (if known) <br />Address <br />r�a <br />PULI¢ WoiMs Pu•mu(�� ����!� �¢� � <br />eme o�ui . _—p%��7113 <br />PubLCWorbPoo _� (1 —m�` <br />Tolal Foe $ �� <br />Less Appl. Fee Paid 5_ <br />I BJIdMB DJO <br />S03 �o % <br />Z.ip <br />uf/n . _ <br />lip <br />Atlach !our (4) copies o� p�ans lor proposed work - Draw �o sCale and noie ihe following as applicable: <br />• Property Lines • Centerline ol street <br />• Outline and dimensions of all existing and • Indicate Norlh <br />proposed s�ructures on ihe lot • Show any proposed c7rading changes <br />• Existing and proaosed utilities • Show measurements <br />� '�u ,5.s <br />Phone <br />77$''�aS�O <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259-8810. <br />2. All work shall be pedormed in accordance with ihis permit and current City of EvereC Deeic�n 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 />^t �..,ly Gl�p-7 i ,_-.0 N /,(i ,'�/"�� � ��r/ /� � C�/ " �i <br />� � �/� <br />everell PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everelt, WA 9d201 <br />Phone:259�8810 <br />ACKNO�VLEDGEMENT OF CONDITIONS <br />The unCersigned owne� � app'ir,ant hereby agrees fo hold and save harm- <br />less ihe City ol E��er. rt from any and all claims for damages, cos�s. <br />expenses. or cause! of action that may arise because of installation <br />and maintenance of �he improvement or other nghFof-way use herelo <br />applied lor and further agrees to remove same upon notice from ihe <br />Ciry and to replace public property damaged thereby. <br />�—�7 �j /,: <br />/ lZc;�<�.� L� �.t. . c�lU;, j'1 <br />Signature of Applicant Date <br />WORK AUTHORIZ[D �Y 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 MAV BE <br />CANCELLED BY THE CITY UPON ANY STOPPAC;E OF V✓ORK ON THIS <br />pROJECT OVER 90 DAVS DURATION. <br />J <br />