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I <br />Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />F f % i� i tlSiF-F-- .3 /oti-4 a'*<sr N. tv <br />Owner Matting Address City <br />Public Works Permit + . <br />SIM. Dept. • -- <br />°ublic Works Fee !i <br />Total Fee <br />Less APOL Fee Paid <br />Balance Doe $ <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work bz6n l2,2— F'G44 i124 i—e F� •S �%�-r.�.Sf�FC'%/!�/j,� <br />LU <br />Project Address (if known) 7� �• O — f/FA7i/i'C•— <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the fol:owing as applicable: <br />• Property Lines • Centerline of street <br />• Cutline 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 /M <br />DO NOT WRITE BELOW T-IIS LINE <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />2. All work shall be performed in accordance with this permit and current City of 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. <br />JZO Luce,c in .8E Z�w✓c !c%ice%�tJ�i ��F �i'��.�, O <br />7a <br />CL � O <br />ma 's/in am <br />Approved for Construction ;-Da;e <br />FINAL INSPECTION Dare <br />Approved as Constructed <br />i <br />PUBLIC WORKS DEPAR1TfEf•-- <br />Ever Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <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 of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace <br />public property damaged thereby. <br />SigKature 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 />