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Date� � <br />Application For <br />PUBLIC WORKS PERMIT <br />Frint or Type Only <br />-uwner - Mailing Address <br /><�/��/�1]�� <br />_ V c�t/ I/ l.r l <br />Applicant Mailing qddress <br />Describe Proposed Work �� ��' � <br />Prolect Address (if known) <br />��. <br />Zip <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existinc� and <br />proposed structures on the lot <br />• Existing and propcsed utilities <br />PuOim Works Pe`mii M, <br />' �; __- <br />Bidg. Cept � _�j ' 1 � � __ <br />Pu�lic Woris Fee <br />Tolal Feo $ _ _ <br />Less ApO�� Feo ?aid $ __ <br />dalance0ue $�i <br />• Centerhne ot street <br />• Indicate North <br />• Show any nroposed grading changes <br />• Show measurements <br />PFRMIT CONDITIONS <br />1. All �alls fer inspection shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be performed in accordance with this permit and r.urrent City ol Everett Design and ConsL•uction <br />Sirindards and Specifications. <br />3. Csll Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-$00-424•5555. <br />for Construction <br />�����.��, 1�,�d �i;2��2�,; �, � � ����n <br />��L,��°'L��, �;�'�Z���{��l�Cr���; L�C1_�C(,�� <br />� <br />ACKNOWLEDGEMENT OF CONUITIONS <br />� <br />�� <br />� <br />Z <br />O <br />The undersigned owner/applicant hereby agrees lo hold and save harm- <br />less the Gity of Everett Irom any and all claims for damages. costs. <br />expenses, or causes of aclion iha! may arise because of installation <br />and maintenance ol the improvement or other right-of-way use hereto <br />Date applied for and further agrees to remove same upon notice hom the <br />City and to replace public property damaged ihereby. <br />FINAL INSPECTION D2te <br />Appro.ed as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200CedarStreet <br />Everett, WA 98201 <br />Phone: 259-8810 <br />of ApP;iCa�t <br />Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIiV <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT IdAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF N�ORK ON THiS <br />PROJECT OVER 90 DAYS DURATION. <br />