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�� <br />�� <br />Date �� �o � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />_2� <br />- <br />Pubii[ Works Parmit t � � �" �� <br />eiae. oco�.. <br />a�m�c woih: Fee $ 2A. C7 0 <br />TotalFee <br />Less AppL Pea Paitl $ �r� <br />BalanceDue $ �"' � �'� <br />� a. �.-� L / � <br />Applicant Mailing Address City Zip Phone <br />Describe PropQsed Work <br />Prolect Address (if known) <br />Attech four (4) copies ol plans (or proposed v.�ork - Draw to scale and note the following as appficable: <br />• Properry Lines • Centerline of slreet <br />• Outline and dimensions of all existing and • Indicate North <br />proposed struclures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />t. All calls Ior inspeclion shall be made 24 hrs in advaoce - phone 259-881 5. <br />2. All work shall be performed in accordance wilh this permit and current City ot Everett Design and Construction <br />Standards and Specitications. <br />3. Call Location Underground Service 48 hrs. Lefore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />/' QC.fw..�— �y '��'' wu:1� �.� �fl'scr`i�r�\! �'i�.,v � <br />Q v�� � S �n s� �.�-u `�•C kSr JC � <br />C�,� <br />1 <br />b I �15, � �� ��� � n.�,�-, �-� � � .� <br />lor Construction <br />'C1 -O <br />Date <br />FINAL INSPECTION Date <br />Approved as Construcled <br />evemtt PUBLIC WORKS DEPAP�� MENT <br />� 3200 Cedar Strect <br />Everett, WA 98201 <br />Phone: 259�8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned ownedapplicant hereby agrees to hold end save harm- <br />less lhe City ol Everett irom any and all claims for damages, costs, <br />expenses, or cnuses of action that may arise because of installalion <br />and maintenance of the improvement or other right-ohway use hereto <br />applied for and further agrees to remove same upon notice irom ihe <br />City and to replace public properry damaged there6y. <br />Signature ol Applicant Uate <br />WORK AUTHURIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THERFAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS P[RMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORY.ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />� <br />w, <br />� <br />