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�w <br />Date <br />Application For <br />PUBLIC; WORKS PERMIT' <br />Print or Type Only <br />Ma <br />Mom.: <br />Public Works Permits -. O ,ro' —3J `3 <br />Bldg. Dept. s 84 _ / / 'l6Dz <br />Public Works Fee <br />Total Fee s <br />Less Adel Fee P.,d S <br />Balance Due S r�Q 00 <br />77,9-e000 <br />dGt>�tIE.G _ <br />Applicant Mailing Address :ity Zip Phone <br />Describe Proposed Work _ IV6_1 / 6- <br />Project Address (if known) <br />Attac.l four �4) copies of plans for proposed work - Draw to scale and note the following as applicable <br />• Property Lines <br />• Centerline of street <br />• Outline and dimensions of all existing and <br />• Indicate North <br />proposed structures on the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />Tile FLL .�l9CECJ OiJ T,/iS —, 7 4 . 7S LbitlE <br />Sn iti .9N u.vsAr�SF4C7r',ey snA vVE2, <br />40AZ1e,gW7_ 6W,-94I dE <br />Docu _) To 1Q1VO1S7've.8EO SQiG Fo,e <br />Forir�G� Ta T.SiE Sgr.rFH,'Tioit/ of <br />TtisPEcTve <br />Approved !o(ConstructionDate <br />F)N< INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />n <br />to <br />co <br />O <br />n <br />z <br />O <br />l�ai,� Oi<dlr <br />a <br />ACKNOWLEDGEME14T OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of instaltation <br />and maintenance of the 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 thereby. <br />ignature of Applicant 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 BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />