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r <br />L <br />Appllcation For <br />PUBUC WORKS PERMIT <br />Print or Type Only <br />� <br />Address <br />PUEIIe Works Permll • <br />OIOp. Dapl • �� ��' �� <br />Pu01ic Works Fee <br />ToUliee S <br />Lesa �ppt Fee PeiE S <br />Belanca �ue s <br />Pro�ect Address (if known) <br />Attech (our (4) copfes of plans for pioposed work - Draw to scale and note the following as applicable: <br />• Property Linea <br />• Outline and dimensions of all existing and <br />proposed siructures on the lot <br />• Existing and proposed utilities <br />PERMITCONDITIONS <br />• Centerline of street <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measurements <br />t. All calls for inspection shall be made 24 hra in advance • phone 259•8815. <br />2. All work ahell be performed in acco�dance with this peimit and current City of Everett Design and Construction <br />Stande�ds and Specifications <br />3. Call Locat(on Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424-5555. <br />�U <br />A�� <br />�%P�"". � <br />pH bl« ///� <br />����� <br />�%PSµ�iCteY <br />/� <br />/ lCS��\I <br />ir� /f b'^ S/dE' �i., <br />G�� / <br />S�/ � ���rsrio .� <br />te P <br />2K�S�/^( <br />d � ��.' �P/ " <br />�-�-Fy <br />ACKNOWLEDGEMENT OF CONDITIONS <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />W <br />� <br />� <br />� <br />O <br />The undersigned owner/applicant hereby a9rees lo hold and save harm- <br />less the City ot Everett irom 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 antl further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br />8E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCE�LED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 50 DAYS DURATION. <br />J <br />� <br />� <br />�� <br />_ . '1 <br />