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Date ��� r "" <br />A�plication For <br />PEJSLIC WORKS PERMIT <br />Print or Type Only <br />mamn3naaress <br />cny <br />Puolm Warks Perm� <br />61d9 Dept + �_ <br />Publ¢ Wo�k9 Fpo <br />To!al Fee $ <br />Less Rppl. Fee PaiE $ <br />Balunce Oue $ <br />Phone <br />Descril�e Propased Work TP� i ���✓T_ _ <br />Prolect Address (il kn�,vrn) <br />Attach tour (4) copies o� nlans for proposed work - Draw to scale and note the following as <br />• Properry Lin2s <br />• f)utline and dimensions of all existing and <br />proposed structures on the lot <br />6 Existing and proposed utilities <br />• Cenle�line of streel <br />• Indicaie North <br />• Show any propos�d grading changes <br />! Sho�v measuremenis <br />PFRMIT COIJDITIONS <br />1. All call; fe• inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall 6e pedormed in accordance with thic permit and current City ot Everelt Design and Construction <br />Standards aud Specifications. <br />3. Call Location Underground Service 48 hrs. betore you dig. TOLL FREE NUMdER 1•800•424•5555. <br />ConstruCtion <br />FINAL INSFECTION <br />Approved as Consruch:d <br />evere[[ I PUBLIC WORKS DEPARTMENT <br />� 3200 Getlar Street <br />Everetl, WA 38201 <br />Plione: 259�8810 <br />nC�1-- ���I t��� <br />ACKNOWLEDGEM[NT OF CGNDITIONS <br />� <br />� <br />O <br />a <br />The undersi9netl owner/applicanl hereby agrees to hold and save harm� <br />-- lees th? C�ty of 'cveielt fwm any and a9 claims lor damagcs, costs. <br />expenses, or causes of ac�ion that may .3rise because of �nstallalion <br />antl maintenance of th�� impro��=men1 cr other ric�ht-ol-way use h�reto <br />— applied for and huther agrzes to remove same upon notice from the <br />Date Ciry and to replac, puUlic proFe•ry damagec thereby. <br />Dale I - —.— <br />��gnalure of Applicant Date <br />IVORK AUThiORIZEU BY THIS PERMIT MUST BE STARTED `.NITHIN <br />�80 DAYS OF DATE PERMIT IS ISSUED AND THEREAFT[R IS TO <br />❑E DILIGENTLY PURSUcD TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGF JF WOFK ON THIS <br />PROJECT OVER 90 DAYS DUR4TION. <br />