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Date� � <br />� <br />(� <br />Appiication For <br />PUBL�C WORKS PERMIT <br />Print or Type Only <br />Mailing Address <br />address <br />Describe Proposed Work � Z <br />� <br />Proiect Address (i( known) <br />PuElie WOrki Pe�mit • <br />emc.oea�.0 9//3�Gr�f <br />r- <br />Pu01ic Wcrka Fee <br />TatelFee $ <br />Less Appl Fee VaiC $ <br />Balance Uue S <br />Zip - <br />Gily Zfp <br />, <br />Attach four (4) copies ot plans for aroposed work - Dmw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on lhe lot <br />• Existing anA oroposed utilities <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CON['ITIONS <br />1. All calis fo� insp?ction sh211 be made 24 hrs. in advance- phone 259-8810. <br />2.All worK shall be peAcrmed In accordance with this perTit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Cali Locatton Underground Service 48 hrs. befcre you dig. TOLL FREE NUMBE21-800•424•5555. <br />Y'�l!Lr-�� CC%L�v/"�CiYi++-'-C'�.� v�-�S'- <br />� <br />� <br />3 -�/-?/ <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />ev� PUBLIC WORK° DEPARTMENT <br />3200 Cedar Street <br />Evered, WA 98201 <br />Phone:259�8810 <br />77Y- ��// <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />_ / <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less lhe City of Everett from any and all claims for damages, cosis, <br />expenses, or causes ot action Ihat may arise because of installation <br />and maintenance of the improvement or other right-o(-way use hereto <br />applied tor and further agrees lo remove same upon notice from the <br />Ciry and to replace public property damaged thereby. <br />Signature ot Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAf-TER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PER�r11T MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOFh ON THIS <br />non�_ -�"er_.�nn. en -.r�n�i <br />