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Date Q 14 ) <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />87 - o <br />Public Norks Pam Bldg. DeP,. + y. <br />Public Works Fee 9- <br />Total Feu <br />Less APPt Fee Paid $OD <br />Balance Due <br />11i[ Clty Zip Phone <br />Applicant Mailing Address <br />Describe Proposed Work — 2 <br />W <br />,J p <br />Project Address (if known) 7J <br />Attach four (4) copies of plans for proposed work - Draw to scale and note t'le following as applicable: <br />Y Centerline of street <br />• Property Lines <br />• Outline and dimensions of all existing and • Indicate North <br />• Show any proposed grading changes <br />proposed structures on the lot <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />.O <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />in with this permit and current City of Everett Design and Construction <br />2. All work shall be performed accordance <br />Standards and Specifications. <br />Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800.424-5555. <br />3. Cell Location <br />5[ bq A107 OL%Fi2 /n/TO OTq iG <br />O <br />LOTS Ac' Lrx.l �Y'9i.iJ�CrE- A�t/9. <br />S, TNt SiLE« tyc C A.vO v� �rif.+/.ay .�1 E A/c'st/ A.✓o ,Gnrd.�'O.E, <br />♦�� <br />)g,✓j/ 4WInw&-' SiN,Lc dE kJ5f4,4czro Rl .9,00e1t,9,V7-. <br />O <br />a <br />, <br />Approved for Corist u Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />ACKNOWLEDGEMENT 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 installation <br />and maintenance of the improvement or other riyht-ef-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and tgxeplagp public property damaged thereby. <br />Igna ure of Ap ican 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 />