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Date �3 <br />Application For <br />PUBLlC WORK� E�EF�MfT <br />Print or Type Only <br />� <br />,✓n <br />Z .1�� G � �' v <br />lina Address <br />o�r�<-ci <br />Applican� Mailin� AdAress <br />Describe Proposed N/ork T � <br />/hR L L G✓n <br />City <br />City <br />Project Address (if known) ( �^ P � nL���I— �`�-� '�3 � <br />� P�Eim Wo�ks Permil � __ <br />: o:oa oeo�.: C S' S_Y� _ <br />�— <br />FvbLtWorl'sfee � <br />Tol:..fee — <br />1e55 FOP� Fee PaN 5 <br />Balance wo $ <br />^'�.��`�'-/ 593J <br />Zip Plione <br />Zip Phone <br />Atlach fodr (4) copies of plans for proposed work � Draw to scale and note the lollowing as applicabie�. <br />• Property Lines <br />• Outline and dimensions of all existing and <br />p�oposed slruclures on the lot <br />• txi,Iing and pro(�osed u�ilities <br />e Center!;ne of siree� <br />O Indicate Nerth <br />O Show any proposed grading changes <br />�� Show insasurrments <br />PERA1IT CONDITIONS <br />t. All r.alls for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pzdurmed in accordance with this parmit and current City ot Evered Design and Cons�ruction <br />Star+dards and Specifications. <br />3. Call Location Underqround Service 48 hrs. before you dig. TOLL FRE� NUMBER 1•SVO•424•555�. <br />'t-�u � �': �- l.�lorks t��,-w.:t- jVo<� '�-g��:�i� <br />���,�� <br />.� g-� <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Construc!ed <br />•_verett PUBLIC WORKS DEPARTMFNT <br />� 3200 Cetlar Street <br />Everett, WA 98201 <br />Phone:259�881� <br />ACKNOWLFDGEMENT OF CONDITIONS <br />W <br />� <br />e <br />� <br />� <br />O <br />� <br />N <br />O <br />a <br />The undcrsigned owner/aFPlicant hereby agrees to hold and save herm- <br />less the City of Everelt from any and all claims lor Aamages, costs. <br />expenaes, or cau�es of action that may anse becaose ol installation <br />and mainlenance of ihe improvement or ciher righl-of�way use hereto <br />applied lor and fcrther agrees to remove seme upon notice from the <br />City and to replace p�, blic properry n•imageC lhereUy. <br />Signature of Applicant Dale <br />WORK AUTHORIZED BY THI� PERMIT MUST BE START[D WITHI�I <br />1B0 DAYS OF DATE PERMI' IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENiLV PURSUED TC'�.OMPLETIOPI. THIS PERMIT MAY B[ <br />CANCELLED 2Y THE GTY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />