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Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mai4ing <br />583z ! <br />Mailing Address <br />� <br />Public Works Permi� ♦ �— <br />Bltlg. Oepl. s <br />PuEllc Works Fee s <br />total Fee <br />Less Acp� Fee PeiA $ <br />Balance Due S <br />�vT. gBZQ'- 353 <br />Ciry Zip I Phone <br />;.�1c L�. ���--�5 ��- 5 <br />Describe Pro osed Wurk G�'���T'e ���"�1� — �«�fj �� �� <br />ProlEct Address (if known) `�""" ,� '� - - <br />Attech tour (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />pro; osed structures on the bl <br />• Existing and proposed utilities <br />• Centerline of street <br />• Indicate North <br />• Show any proposed gradinc� changes <br />• Show measurements <br />PERMIT CCNDITIONS <br />1. All calls for inspection shall be made 24 hrs. in aG�ance - phone 259•881 5. <br />2. All work shall be performed in accordancr with this permit and current City ot Everett Design and Construction <br />Standards and Specifications. <br />a. Call Lor.�tion Underground Service 48 hrs. before yo� dig. TOLL FREE NUMBER 1•800-424•5555. <br />/�✓ ir'(/BC�C /-vo,�.��' <br />ioF2�-iii .t�'qvi�r.O <br />Approved for Construction Date <br />=�,P,� //- � -� s <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Streel <br />Everett, WA 98201 <br />Phune: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersi9ned owner/applicant hereby agrees to hold and save herm• <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 ol the improvement or olher righbof•way use hereto <br />applied tor and further ayrees to remove same upcn nolice from the <br />City and to replace public proparty damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERtvl1T 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'fHE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />� <br />.. .. <br />--1 TI <br />�� <br />N S <br />m <br />co <br />mo <br />n <br />O 3 <br />m <br />_ -�i <br />m <br />o z <br />a -a <br />r x <br />.-� ... <br />—� N <br />< <br />"�7 <br />O A <br />'�1 D <br />-� m <br />x <br />m .. <br />N <br />v <br />o r <br />c� m <br />3 tNi� <br />m <br />�� <br />m <br />a <br />z <br />-a <br />x <br />a <br />z <br />--1 <br />2 <br />N <br />Z <br />0 <br />� <br />.. <br />� <br />m <br />