Laserfiche WebLink
Date � ���� <br />ApPlication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />—L�� <br />AppliCa��l Idaiun9 Address <br />Describe Proposed Worh <br />Projed Address (if known) <br />� 1 .�''K�f=f'- �--��FT <br />a�y z� <br />Qiy Zi <br />-�r 1V ( CTl l� Il.-. i' ti'J <br />Attach four (4) copies of plans br proposed work • Draw to scale and note the following as apPlicable: <br />• Property Lines <br />• Outline antl dimensions ol all exis�ing anA <br />propo5ed 51rUCWreS on the lot <br />• Ezisting and proposed utilities <br />�,.�,��� t•,a,�<<-o�- )� � �s <br />Giaq Deo� • <br />c �i� l_� n -1� <br />Pu�uc\Ym�aice <br />Totai Fee 5 <br />LessAnnl fnevaiG S <br />Belencn0ue .i <br />• Centerline of sireet <br />• Indicate North <br />• Show any prop�sed gradinn changes <br />• Show measurements <br />ne <br />Phone <br />PERMIT GONDITIONS <br />1. All calls for in�pecNon shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be performed in accordance with this permit and curren� City of Everett Design end Construction <br />Stsrderds and opecifications. <br />3. Call Location Unde�ground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />, •.7 . /� / l �' � <br />/�`-�c.iC! �C .^�'z�/_Ctl.�i�<.! /�"[���C! C �:"!� � �-�/-�/�5�� <br />� � �'�. � <br />Approved lor Construction <br />Date <br />FINAL INSFECTION Date <br />Approved as ConsVucled <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200CedarSVeet <br />Everett. WA 9g201 <br />Phone: 259�8810 <br />ACKNOWLEDGEM1IEN7 OF CONDITIONS <br />W <br />F- <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersic�ned owneUapplicant hereLy agrees lo hold and save harm- <br />less �ne Gty of Everetl irom any and all claims lor damages. costs. <br />enpenses, or causes ol ac�ion that may arise beCause of install�lion <br />and maintenance of the improvement or other n7ht-of�way use nereto <br />applied for and lurther agrees to remove same upon notice Irnm the <br />City and lo replace puhlic property damaged thereby. <br />Signature ol AppGcant 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 8E <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />