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�ate�2� C�' <br />Applicetion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />naaumg qdaress <br />Describe Proposed Work �1 �� - <br />Project Address (if known) <br />2ip <br />Zip <br />Attach four (4) copies o1 pinns (or proposed work - Draw to scale and note the lollowing as applicabtr.: <br />• Properiy Lines <br />� Outline and dimensions of all existino and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PERMIT CCNDITIONS <br />Puol¢worASPer . ��'��� <br />eiao. oeo�.• � �� <br />Pu�hp Works Peo <br />Toinl Fee S <br />Less AOGI Fce Peid : <br />Balance Due S <br />ZC� pe <br />• Cenlerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />t. All calls tor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shzll he performed in accordance with this permit and current City ol Eveiett Design and Construction <br />Standards and Specifications. <br />3. Call Lccation Undergrountl Service 48 hrs, be(ort� you dig. TOLL FREE NUMBER 1•800•424-5555. <br />���1��,e5�.l�c�a-�� /o� S 8h <br />Approved for onstruction Date <br />/ <br />i—T—� �/ ��'� � G -7 <br />� ��� � �G�ti�_3 —�- �'A / <br />PIW�L INSPECT�ON Dat <br />Approved as Constructed <br />evc« •tt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-B815 <br />ACKNOWLEOGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby ac�rees to hold and save harm- <br />less Ihe Cily ol Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and mainlenance of the improvement or other right-ol-way use hereto <br />applied lor and further ac�rees to reniove same upon notice Irom Ihe <br />City and to replace public property damaged thereby. <br />-�-9-�G <br />gna ure oi Applic nt Date <br />WORK AUTHORI ED BY THIS RMIT MUST BE STARTED WITHIN <br />780 DAYS OF DATE FERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERh11T MAY BE <br />CANCELLED BY THE CITI' UPON ANY STOPPAG[ OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURA'i �ON <br />