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9 t-3 rA <br />HEM <br />1< H <br />H At <br />N H <br />x <br />HC <br />OS <br />/ 08 <br />17V Q <br />zHS <br />yyHz <br />rHH <br />8N <br />la t:1 C��i4-yI <br />Z H rye <br />HON <br />C1 1 <br />` Date � <br />Application For <br />PUBLIC WORKS PERMIT <br />CJ <br />Print or Type Only <br />R <br />T <br />Public Works Permit a 1G V <br />aleo Deal.. <br />Public Works Fee <br />Tolal Fee $ <br />Less APPt Fee Paid a <br />Balance Due � <br />35 0 0° <br />ODZ-32011e;179 3/ <br />Describe Proposed Work C�/'O[Jro r�<� "nSU�[ir�r/� <br />7�xtta lL 2Yc'>ui cx� �c/4 fn r� <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-881 n. <br />2. All work shall be performed in accordance with this permit and current City . f Everett Design and Construction <br />Standards and Specifications. - <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555.1 <br />Tf�Ecf /J�1{ BI foic/ Sys r� /+� N f 6�%JTE�: / d/hS //V 7//F A/'r/{ / <br />Approved for n lion Date <br />FINAL INSPECTION Date <br />App� rived as Constructed r <br />PUBLIC WORKS DEPARTMENT <br />MIML <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />z <br />O <br />O <br />a• <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for dam:.ges, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-ol-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 />a , �aitg-Yy- <br />7, <br />Sig ature of Applicant Date <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 />ff <br />