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Date <br />Appllcation For <br />WUBLIC WORKS PERMIT <br />Print or Type Only <br />Pu�lic Wo�ka Parmi� • <br />Bma Deo�� + — <br />Pu�lic Woek6 Fee <br />Tolal Fea s <br />Lesf AOVI Fee Peitl S <br />BalanceDue S <br />Address <br />Desc�ibe Proposed Work <br />a�y <br />Proiect Addreas pt known) -� '"' "f <br />Attach four (4) copies of plens for proposed work • Draw to scale and note the following as applicable: <br />• property Lines <br />• Outline and Eimensions of all existing and <br />proposed structures on Ihe lot <br />� Ezisting and proposed utilities <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />rnone <br />PERMIT CONDITIONS <br />1. All calls for inspection shail be mede 24 hrs. in advance • phone 259-8810. <br />2. All work shall be peAormed in accordence with this permit and current City ot Everetl Design and Canstructton <br />Stendards and Specifications. <br />3. Cell Locetion Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800�424•5555. <br />p� [A�eGE R�Fc�-ercRS <br />� FLAS����G B�RR���E�� A-r ��T1f�K �ND oF Du�tPS�"2 <br />0 <br />PERM=r vau� MARcN i7 -rt�,e���µ <br />��--��2.,., �, 3 �� l� ` �l 0 <br />Approv� nstruction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PU6LIC WORKS DEPARTMENT <br />� 3200 Ceder Street <br />Everett, WA 98201 <br />Phone: 259-8010 <br />MA��t� 19 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hold and save herm- <br />less the City of Everett irom any and all ciaims tor damages. costs. <br />expenses, or causes oi action that may arise because of installation <br />and maintenance ot the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice irom the <br />City and to replace public property damaged thereby. <br />/",.�.0 . /�JLE <br />Signafure Applicant/ / Date <br />WORK AUTHORIZED� Y THIS PERMIT MUST BE STARTED WITHIN <br />1B0 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 WOPK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />