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Date��� <br />Application For <br />PUBLiC WORKS PERMIT <br />Print or Type Only <br />Adtlress <br />� <br />� ��A � <br />Applicant Maihng Add�eso City Z�P <br />Describe Propoeed Work <br />Projecl Address (il known) �7 1s— —'� <br />nu�eh (our (41 cooies ot Plans for proposed work - Draw lo scale and note ihe following <br />• Property Lines <br />• Outline and dimensions ol all existing and <br />proposed s�ructures on ihe lol <br />• Existing and proposed utilities <br />Pubiic \'brhs Permtl + <br />eiea oeo� . fr�� / Ci �70 �— <br />Publ�c Wo�ks Fee 5 <br />Tolal Fee <br />Less A001. Fee Pa�a $ <br />Balance Due g <br />• Centerline of sireel <br />• Indicate North <br />• Show any proposetl grading changes <br />• Show measurements <br />Phone <br />PERMITCONDITIONS <br />1. All calls fo: inspection shall be made 24 �irs. in advance - phone 2�5-8810. <br />2. All work shall be peAormed in accordance with this permit and currer.t City of Everett Design and L'onstruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. betore you dig.70LL FREE NUMBER 1•800•424-5555. <br />/�>n. i ,?�' <br />ApproveA �or Consiruclion <br />3/'si� <br />�'/1/(/Ll'L, <br />/ <br />Date <br />FINAI INSPECTION Date <br />npproved as Constructed <br />everett PUBLIC WO:iKS DEPARTMENT <br />�� 3200CedarStreet <br />Everett. WA 98201 <br />Phonc.254-8810 <br />ne <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />7/ <br />ihe undersi9ned owner/apPlicant hereby agrees to hold and save harm� <br />less the City of Everett from any and all claims lor damages, cosis. <br />expenses, or causes oi aclion that may arise because of installation <br />and maintenance ot lhe improvement or other righPot�way use hereto <br />applied lor and lurther agrees to remove same upon notice Irom Ihe <br />City and to replace public property damaged �hereby. <br />Si9nature ot AFPlicant Date <br />WORK AUTHORIZED BY THIS PC-RA11T MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTE� IS TO <br />BE DILIG[NiLY PURSUED TO COMPLETION. THIS PERMIT AIAY BE <br />CANCELLED BY THE CITY U�ON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />