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Date Application For <br />PUBLIC WORKS <br />Print or Type Only <br />Describe Proposed Work <br />PERMIT <br />TO <br />PI1STlNG . IL�._ 5-=- <br />Public works Permit a -- <br />Bldg. Dept a ---- <br />Public works Fee <br />10181 Fee <br />Lass Appl. Fee Pud S <br />Balance Due <br />Protect Address (if known) <br />Ilcable: <br />Attach four (4) copies of plans for Proposed work •Draw to scar and note 0 following Centerline of street <br />• Property Linea • Indicate North ceding changes <br />• Outline and dimensions h Show measurements <br />all existing and • Show any Proposed g <br />e lot 0 <br />proposed etruatureoson ad utilities <br />D oO <br />• Existing and P <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS Design and Construction <br />1. All calla for Inspection shall be made 24 hra in advance -Phone 25¢$81 O. <br />mit and current City Of <br />2. All Work shall be Ps it accordancer��&B befith ore Yis ou dig. TOLL FREE NUMBER 1t loo.4Z4.5 ,55. <br />Standards and Spec Service O <br />3. Call Location Underground <br />Yrrvnl a.�• -- - - <br />Approved as Constructed <br />PUBLIC WORKS OEPARTM-NT <br />gYCedar Street <br />Everett WA 98201 <br />phone: 259-8810 <br />IN a <br />ACKNOWLEDGEMENT OF C agrees tolhONS <br />old and save harm, <br />The undersigned owner/applicant hereby <br />less the City of Everett from any and all claims for damages- costa <br />arise because of installation <br />use hereto <br />expenses, or causes of action that ^t n notice from the <br />and maintenance of the improvement <br />eremovetsameuhpo f-way <br />applied for and further a9 damaged thereby <br />Date City and to replace public property <br />Date <br />Date gignatur pp!icant <br />THEREAFTER IS TO <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED <br />MAY BE <br />180 DAYS OF DATE PERMIT IS ISSUED I <br />BE DILIGENTLY PURSUED TO COMPLETIOt. <br />PROJECT OVER 90 DAYS DURATION, STOPF Rom- uF WORK ON TIiIS <br />