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Date � a �o <br />Application For <br />PUBLIC WORK� PERMIT <br />Print or Type Only <br />�i <br />nuu�eaa <br />Oescribe Proposed Work <br />Project Address (if known) <br />� <br />Pu�lic Worka Perml� s <br />BIOq. Oept • � ��_ <br />Public Worka Fee <br />Total Feo � <br />Less AppL Pee Paid 5 <br />Belance Due $ <br />Altach four (4) copies of plans for proposed work - Draw to scale and note the tollowing �s applicable: <br />• Property Lines • Centerline of sireet <br />• Oulline and dimensions of all exisling and • Indicate North � <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and p�oposed utilities � O Show measurements <br />PERMIT CONDITIONS � <br />t. All calls for inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in accordance witfi this permit and current City of Everett Design and Construction <br />Standariis and Specifications. <br />3. Call location Underground Service 48 hrs. bafore you dig. TOLL FREE NUMBER 1•800-424-5555. <br />�� �vo^CiC �o,c�� s <br />a>:' <br />' `,, ,- `' <br />I 4 .. <br />l�cSC��ii�T �PEy,o�.c�l-� <br />r <br />. �� jz/�y <br />Approvetl ior"Construction Date <br />FINAL INSPEC?ION Date <br />Approved as Constructed <br />everett PU9LIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everelt, WA 98201 <br />Phone: 259•8815 <br />� <br />� <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />less the City of Everett from a�y and all claims for damages, costs, <br />expenses, or causes o( action that may arise because of inslal!ation <br />and maintenance ot the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice Irom the <br />City and to replace public property damaged thereby. <br />Signature of Apphcant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />Z <br />O <br />� <br />�-r <br />n <br />m <br />�. .-. <br />--1 �'I <br />.-y —{ <br />Vt 2 <br />v <br />m <br />co <br />mo <br />—I G' <br />O 3 <br />m <br />i -Zi <br />m <br />A Z <br />c <br />r = <br />H I-Y <br />--� N <br />< <br />'�l <br />O .� <br />TI D <br />-i m <br />m .-. <br />N <br />or <br />c� m <br />C N <br />3 (n <br />z c� <br />--i r <br />• m <br />A <br />A <br />� <br />_ <br />a <br />z <br />� <br />� <br />N <br />z <br />0 <br />�,i <br />n <br />m <br />