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1xy-3 En <br />fC C) <br />H� <br />H Nr <br />MoA <br />H t7 <br />O H ty <br />H C08 +1 <br />4] Y <br />Hz <br />HH <br />y <br />gd� <br />IRV <br />H O rrAA <br />F <br />Date_"21 _1 J <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Describe Proposed Work An" i C )IC y f <br />M <br />Pubac Wods Per <br />Bldg -Dept <br />Publie Work%Foe $ <br />Total Fee <br />Less appl. Fee Paid S <br />Balance Due 5 <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work- Draw to scale and note <br />a following as applicable: <br />• Property Lines <br />• Centerline of street <br />• Indicate North <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259.881 D. <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 his, before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />No PA', ?(CQ <br />Approved for Construction Date <br />FINAL INSPECTION Dale <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />Ever Ceder Street <br />Everett, WA 98201 <br />Phone: 259-8810 <br />Iz- 9-P:I <br />LU <br />I. <br />co <br />0 <br />01 <br />0 <br />F-- <br />0 <br />a <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 for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant Dale <br />WORK AUTHORIZED BY 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 MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />I <br />