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Date�� � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />� �_3q6. - <br />Public Works Permi�l x%� <br />Bltly. Depi. e �( /�� <br />Pu�lic Works Fee $ <br />Tatal Fce <br />Less AppL Fee Paia � <br />Balanca Due a 20 �o <br />: �L <br />���/�n G� - <br />qpphc" ant Mailing Address City Lp Phone <br />DescNbe Proposed Work ___�_{�-��� �� I l"�T , A) �I I IS � J� i.� <br />Prolect Address (if known) <br />Attach tour (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dlmensions of all existing ard <br />proposed structures on the lot <br />• Existing and proposed utilities <br />I Approved for <br />• Centedine oi streel <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calis for inspection shall be made 24 hrs in advance - phone 259-8815. <br />2. All work shell be peAormed in accordance with this permit and current City of Everett Design and Consiruction <br />Stendards and Specilicei:ons <br />3. Call Location Underground Service 4f hrs. before you dig. TOLL FREE NUMBER 1•800•424•555.ri. <br />� TGl1�.L���E ROA�T�P 1>Oc.�N-S�ov9.� /A/To �/I9i•r/qGc�' <br />S'f/5�.��r S//ouJ�v av 9�yc.Y�p CH/.�.¢T. <br />Date <br />Approved as Constructetl <br />everen PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />� Phone:259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned cwner/applicant hereby agrees to h�oln and save harm- <br />less ihe City of Everett from any and all claims f�r dameges, costs, <br />exuenses, or causes of action that may arise because of installation <br />and maintenance ot lhe 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 public property damaged thereUy. . <br />' � -,1�� �� � �Y <br />Si ature ot Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST EE S ARTED WITHIN <br />180 DAYS OF DATE PERMIT IS �SSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY �� ON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS Dl�'iATION. "-�1 <br />