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Date��J <br />Application For <br />PUBLIC WORKS PERMIT <br />P�e1�cltio�kaPa�mli• �� /�/ <br />eiey. oeo�.. � y� <br />Public Woika Fae s <br />Tolal Fea <br />Leaa Aoa� Fea Peitl S �%`' <br />BelencaDue $ ^v/OO <br />Print orType Only 7�9.�. <br />.=? . r'.r— ? �➢in <br />Applicanl <br />Mailing Address <br />Describe Proposed Work .�]O � �F� <br />Pro�ect Address (if known) <br />Attach four (4) copies of Ulans for proposed work • Dra�x lo scale and note the lollowing as applicable: <br />� Property Lines • Centerline of street <br />• Outline and dimensions of all existing anG • Indicate North <br />proposed struclures on the lot � • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hra. in advance - phone 259•881 5. <br />2. All work shall be perlormed In accordance with this permit and current City ol Everett Design and Construction <br />Standerds and Specilications. <br />3. Call Location Underground Service 48 hrs. befor•: you dig. TOLL FREE NUMBER 1•800•424•5555. <br />Approved lor <br />RfJAL INSPECTION <br />Approved as Consiructed <br />evere[t PUBLIC WORKS DEPARTMENT <br />� 3200 Cetlar Street <br />Everelt, W� 98201 <br />Fhone: 259•8815 <br />� ^L�/ �'/ <br />Date <br />- 3-�,6 <br />Date <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />z <br />O <br />H <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />less lhe City of Everett lrom any and all claims for damages, costs, <br />expenses, or causes of action ihat may arise because ol installation <br />and maintenance ot the improvement or other right�ol-way use hereto <br />applied tor and furiher agrees to remove same upon notice lrom lhe <br />Cily and to replace public property demaged thereby. <br />,,r_�-, �C ,,�5 <br />igna ure of A cant ate <br />WORK AUTHORIZEO BY THIS PERMIT MUST BE STARTED WITHIN <br />1A0 DAYS OF DATF PERMIT IS ISSUED AND THEREAFTER IS TO <br />6[ DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT A1AY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OP WORK ON THIS <br />I PROJECTOVER900AYSDURATION. <br />'L <br />O <br />� <br />�y <br />r� <br />m <br />�� <br />.. -1 <br />N S <br />0 <br />m <br />no <br />� <br />03 <br />�z <br />m � <br />.o z <br />r�- i <br />-1 N <br />< <br />T <br />O A <br />�7 Y <br />-� m <br />x <br />m �-. <br />N <br />0 <br />or <br />n m <br />�� <br />3 tn <br />m <br />z t� <br />1r <br />m <br />n <br />A <br />—I <br />S <br />D <br />2 <br />--I <br />� <br />N <br />Z <br />O <br />--1 <br />� <br />m <br />