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Date ._� 1U <br />� <br />Application For <br />PUBLIC Vi/OF�64S PERMIT <br />Print or Type Only <br />Descrihe P�oposed Work <br />Proioct Address ;if knowy <br />Address <br />� s'�. <br />%,_ �. � <br />� PuC�ic Worke Permit s �"" ��/ <br />eiec.oen�+ �—�r`,5;�,� <br />PuelicworxsFea $ <br />TOlal Fea ,[ <br />Leas Aoal Fee PaiG $ �Y-� _ <br />Balanca Oue S <br />�7"c�,i ��— <br />���y fi;,�� <br />Attach four (4) capies of pl::ns for proposed work • Draw to scale and note the following as appl��a61e: <br />• Property Lines <br />• Outline and dimensions of aI1 cxisting and <br />proposed structures on the lot <br />• Existing and proposed utilities � <br />• Centerline ot stree! <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurcments <br />PERMIT CONDITIONS <br />1. All call: for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All wuik shall be pedormed in accordance with this parmit antl current City of Everett Des�gn and Construction <br />Standards and Specifications. <br />3. Call location Underground Service 48 hrs. betore you dig. TOLL FREE NUMBER 1-800-424•5555. <br />T ��-�-� L�%U'�-�'. �o G�t.[, doxe. �e2 ,a�o�eoz��i ��-,u✓ <br />pz <br />d��'-� �-as- an <br />� <br />,�,�/� <br />ADProved,f � onstruction / ' Date <br />FINAL INSPECTION Date <br />Approved as Constr�cted <br />everett PUBLIC WORKS DENARTMENT <br />� 3200 Cedar Street <br />Everett, lNA 98201 <br />Phone: 259•8815 <br />ACKNOWLEDGEMENT OF CONOITIONS <br />W <br />� <br />� <br />�� <br />� <br />� <br />O <br />� <br />� <br />0 <br />a <br />The undersigned owner/applicant herebyagrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes ol action that may arise because of installatlon <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged �hereby. <br />\l <br />Signature of kpplicant va[e <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTIY PURSUED TO COMPLETfON. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATIOPI. <br />