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Date I �-I�1 �--+ / ( ( Pu�lie Worhs Parmlt e <br /> Appiication For amo.o�oc• <br /> PUBLIC WORKS PERMIT ' ' Pu0licWaWFee <br /> Total Fee S <br /> Lesa ApP�Fae F.Itl 5 <br /> Print or Type Only BalanceDua s <br /> � ��i.. r�'�►� ������ �1�'2 l�;/-�f iqll )X� ��.� q���! 2��f7-7�l� <br /> Owner Maiting Address City Zip Phone <br /> Applicant Mailing Address �ity Zip Phone <br /> Describa Proposed Work <br /> NrolactAddress(if known) �� / � <br /> � <br /> Attach four(4)copies of plans for proposed work• Draw to scale and note the Iollowing as applicable: � <br /> • Property Lines � Centerline of street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utiiities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br />� 1. All celly tor ir�spection shatl be made 24 hrs. in advance• phone 259•8815. � <br /> 2. All work ehell be pertormed in accordance with this permit an'' ���rrent City of Everett�esign and Construction <br /> Standards and Specllications <br /> 3. Cal�Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> noT ��,�i� �r���� O <br />„ �`' F— <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersignad o�•mer/applicant hereby agrees to hold and save herm- <br /> less the City of Everett from any and all claims tor damages, costs, <br /> expenses, or causes of action that may ar!se 6ecause of installation <br /> and maintenance of the improvement or other right-of-way use hereto <br /> applied for and fuAher agrees to remove same upon notice from ihe <br /> Approved fo:Construction Date City and to replace public prope�ry demaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature ol Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERNIT MUST BE SThRTED WITHIN <br /> � 3200 Cedar Sireet 180 DAYS OF DATE PERMIT IS ISBUED AND THEREAFTER IS TO � <br /> Everett, WA 98201 BE DILIGENTLY PURSUED TO COMPLETIUN.THIS PERMIT MAY BE <br /> Phone:259-BB75 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PFOJECT OVER 90 DAYS DURATION. � <br />