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Date �s.._�� I <br />Aopiication For <br />PU6�IC W6RKS PERMIT <br />Print or Type Only <br />r <br />� �, <br />wner <br />�� i i <br />Applicanl <br />Describe ProposeJ Work <br />Address <br />Mailing Address <br />Proiect Address (it known) S�� <br />PUEIic Warhs Pormil � /� <br />r [_. <br />Amu.00ni., _ _ � <br />Pub§c N'crxs Feo S <br />Tota Fea -- <br />Lesi ADV� Fee PniE S `O_� <br />1 <br />Balence Duo S <br />'�=�1�.� �"(�.U� � f'" � j�- <br />Zip � Phune <br />Zip Phone <br />Attach tour (4) copies ol plans for p��posed work • Draw to scale and note ihe following as applica6le: <br />• Property Lines • Centerline of sfreet <br />• Outline and dimensions ol all existing a�..1 • Indicate North <br />{+��posed structures ^n the lot • Show any proposed grxding changes <br />•...isting and proposed utilities • Show measurements <br />PEHMIT CONDITIONB <br />1. All calls lor inspection shall be made 24 hrs. in advance • phone 259•881 O. <br />2. All work shall be performed in accordance .vith this permit and current City ot Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 4C hrs. before you dig. TOLL FREE NUM9ER 1•800•�i24•5555. <br />� <br />Approved for <br />FINAL INSPECTION <br />Approved as ConsVucted <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Evorett, WA 98201 <br />Phone: 259-8810 <br />� <br />ACKNOWLEDGEMENT OF CONGITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned oH�ner/applicant hereby ac�rees to hold and save harm- <br />less lhe Cily of Everett Irom any and all Gaims tor damages. costs, <br />expenses, or causes of aclion lhal may arise because of installalion <br />and maintenance ol 1)rt�nprovement or other right-of�way use hereto <br />applied for and lur agrees to remove same upon nolice trom the <br />City and to repl public properjy.daete9ed thereby. <br />WORK AUT �ORffED BY THIS PERMI�MUST E STARTED WITHIN <br />1S0 OAY�OF DATE PERMIT IS ISSUE THEREAFTER IS TO <br />BE DILIGCNTLY 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 />