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Date��� PuDlic Worke Permn• <br /> BIEp.Oept+�� <br /> Appiication For <br /> PUBLIC WORKS PERMIT Pu�TolaFeeFee g <br /> Less Apo�Fee Paia $ <br /> Balance Due � <br /> Print or Type Only <br /> h���e E ,/� , ��`�l- 1 � E�eretf � �Q � _ <br /> Owner Mai4ing Address Ciry Zip Phone <br /> z <br /> 0 <br /> Applicant Mailing Address City Zip Phone � <br /> m <br /> Describe Proposed Work <br /> .. �-. <br /> � 'r� <br /> � � <br /> Nm <br /> � o <br /> mo <br /> Projecf Address(if known) �1 7 n � ` d� � ��� � �' � �r~� � p m <br /> Attach four(4) copies of plans for proposed work• Draw to scale and note the following as applicable: � _ —L1 <br /> • Property Lines • Centerline of street � m .. <br /> • Outline and dimensions of all existing and • Indicate North Q 2 <br /> proposed structures onthelot • Show any proposed grading changes � _ <br /> • Ezisting and proposed utilities • Show measurements /�/� ... ... <br /> W �' �' <br /> < <br /> DO NOT WRITE BELOW THIS LINE O '� <br /> O 3 <br /> PERMIT CONDITIONS .� m <br /> 1, All calls lor inspection shall be made 24 hrs. in advance � Ghone 259•SL1 5. � _ <br /> 2. All work sha�l be performed in accordance with this pe�.iiil and current City of Everett Design and Construction m N <br /> Standards and Speci�ications. <br /> 3. C�II Location Underground Service 48 hrs. belore you ;;�c;.TOLL FREE NUMBER 1•800•424•5555. � � m <br /> C N <br /> m N <br /> � / O � m <br /> /1/� �//B��G /��/',�- S 1�C,��n�T � <br /> .��'C�U/•r�.'�� � Z <br /> � -� <br /> ��� J �/�s N � <br /> .% � N <br /> Z <br /> � a � <br /> � <br /> � <br /> :� m <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm• <br /> less the Ciry of Everett from any and all claims for damages, cosis, <br /> expenses, or causes ot aclion that may arise because of installation <br /> and maintenance of lhe improvement or other righFobway use herero <br /> applied for and lurther agrees to remove same upon notice irom the <br /> Approved for Consiruction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature of Applicant Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 7g0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Streel 8E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everetl,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 PROJECT OVER 90 DAYf, DURATION. <br />