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Date_�1--� � D <br />Applicalion For <br />PUBLIC WQRKS PERMIT <br />Print or Type Only <br />� C/'PubLc Waeks Pcrmil a <br />eme. oeo�. • �� �_7"'� <br />CuEI¢ Kbrkn Fee 5 <br />Total fce -- <br />Less Fop�� Fee PaiC S <br />�alanca Duc S -- <br />city <br />Applicant '•'"••'..' ..""-- <br />-r����n�.n . - <br />Describe Proposed Work <br />Prolect Address (if known) <br />Attach tour (4) copies of plans tor proposed work - Draw to sr.ale and note ihe following as ap licable: <br />• C nterline ol stree� <br />• Property Lines <br />• Outline and dimensions ot all existing and <br />proposed siructures on Ihe lot <br />• ExisLny �nd pwposed utilities <br />e <br />• Indicate Norih <br />• Show any proPosad yrading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection snall be made 24 hrs. in advance • phone 259-8810. <br />2. All work shall be periormed in accordance with this pe�mit and current Ciry ot Everett Design and Conslruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TQIL PREE NUMBER 7•800-424•Fi555. <br />�1or -�c��i re�n <br />qpproved icr Consiruction Date <br />FINAL INSP=CTION Date <br />Approved as Gonslructed <br />everett PURLiC WORKS DEPARTMENT <br />.,�� 3200 Cedar Sireet <br />�'• cverett, WA 9�201 <br />r� Phone:259-8�70 <br />.�-.s-9s <br />�� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />0 <br />The undersigned owner/applicant heieby agrees lo hold and seve harm- <br />iess the City of Everett trom any and all claims for damagas. costs, <br />er.penses, or causes of action ihal may arise because ol irs!allation <br />and maintenance of the improvement or o�her right�of-way ���eomrthe <br />zpplied lor and furiher agrees to remove same upon notir,c <br />City and to rePlace public Froperty damaged ihereby. <br />SionaWre of Applicant Date <br />WORF: AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE F'ERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO CnMFLETION. THIS PERMIT A"AY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF W(1RK ON THIS <br />FROJECT O`.'ER 90 DAY� DURkTION. <br />