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Date� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />c <br />I.1 h r��� �pr /d <br />Applicant <br />Describe Proposed Work <br />� IP <br />Project Addrass (if known) <br />Mailing Address <br />Attach four (4) copies of plans tor proposed work - Draw to <br />• Property Lines <br />• Outline and dimensions of all existing and <br />. proposed structures on the lot <br />• Existing and proposcJ utilities <br />,_,.,:.:� <br />Pu01ic Works Permil • �O � C ✓�� <br />Blag. Dapl. s <br />Public Worka Fee <br />Total Fee S <br />Less Appl. Fee PaiO S 9 <br />BalanteDue $ J�� <br />� �' <br />Zip <br />and note the following as applicable: <br />• Centerline of street <br />• Indicste North <br />• Show any proposed grading changes <br />• Show rieasurements <br />;i; -, Il-. -, <br />3,��3 ��7 � <br />Phone <br />P�TE <br />?t'3 �l� ) �/ <br />PERMIT CONDITIONS <br />1. All cells for inspection shall be made 24 hrs. in advance - phone 259•881 O. <br />2. AII work shall be performed in accordance with this permit and current City of Everett Design and Constructlon <br />Standards and Specificatione. <br />3. Call Locatton Underground Service 48 hrs. before you dig. TOLL PREE NUMBER 1•800-424•5555. <br />i % �\ � i � / <br />' ,�,�� <br />� , ��\� ' . , . <br />s� /D��� � % <br />C <br />�i� �` �e�'`� <br />�,� s u,S `'"� �� e e s 5 <br />�_/ <br />for <br />�� �� <br />.9rT,9c.y,�o� <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett WA 98201 <br />Phone:259-8810 <br />� / <br />i <br />� <br />� � 06/14/8B 9:13{�f OOORN1047� <br />J QR � <br />� �o�� <br />w.ec szo.00 <br />nECH szi.so <br />ACKNOWLEDG�x'j CONDITIONS <br />The undersi gned o�.vner/a p plic$ fi�eb y a���s�h ol d a n d s a v e h a r m- <br />less the City of Everett from�l��I claims for damages, costs, <br />expenses, or causes of actio��qat,q�ay a� ause of installation <br />and maintenance of the impr hV�n'i or ot 1 t•of-way use hereto <br />applied for and further agree���move on notice irom the <br />ity an o place pu ' roperty damaged thereby. <br />c <br />�� <br />Signature of Appiicant ' ah� <br />WORK AUTHOF�ZeD BY THIS PERMIT MUSI' BE STARTEC `.v;fHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAF�F!i IS TO <br />BE DILIGENTLY PURSUED TO COMPLET�ON. THIS PERMII' MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK Oh THIS <br />PROJECT OVER 90 DAYS DURATION. <br />W <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />