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Date �y�1"'�7 <br />r <br />l <br />Application For <br />WUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Uiiy <br />Describe Proposed Work � nnn � ��lvJ i�f7i /p�(�o� � <br />Project Address (if known) �nZ r �_ L✓Ple, f��/ <br />Attech lour (4) copies of plans for proposed work • Draw to scale and note thr. lollowing as <br />• Property Lines <br />• Outline and dimensions of all existin9 and <br />proposed structures on the lot <br />• Exlsting and proposed utilities <br />PERMIT CONDITIONS <br />{ PublmWoiksPormils � <br />61tlq. Depl. � � Z <br />Pu�lic Woiks Fea <br />total Fee s <br />la4s Appl fue PeiO � <br />Bnlnnce Ouo $ <br />S�U — <br />�P �J�Si()� '�`f�—S8'Lc, <br />Zip � Phone <br />Zip �h�ne <br />� Centerline of street <br />� indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />1. All calls for inspection shall be made 24 hra in advance - phone 259•8815. <br />2. AI� work shall be performed in nccordance with this permit and current City ol Eveiett Design and Construction <br />Standards and Specifications <br />3. Cell Location Underground Service 48 hra belorc! you dig. TOLL FREE NUMBER 1•800•424-5555. <br />/�/DT �P�C�Ui,£'�',p <br />�o� �— O �8 / <br />(-� � <br />?��� <br />Approved for Gonstruction Date <br />FINAL INSPECTION Date <br />Approved as Cons!ructed <br />everett PUBLIC WORKS OEPARTMENT <br />� 3200 Cedar Street <br />Everet6 Wq g8201 <br />Phone:259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Evorett Irom any and alt claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the impruvement or other right-of-way use hereto <br />applied for and lurther agrees to remove same upon notice from thc <br />City and to reFlace public property damac�ed thereby. <br />SignaWre ol 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 />CANCtLLED BY TI1E CITY UPUN ANY STOFPAGE OF WORK ON THIS <br />PROJECT OViSR 90 DAYS DURFTION. i'— <br />