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Date <br />Application For <br />PUBLIC WORKS PERMI� <br />Print or Type Only <br />Owner <br />Applicant <br />Dascribe Proposed Work _ <br />Project Address (if known) <br />Plan Check No: <br />Applicat.Date: <br />Job Address: <br />owner: <br />Tenant: <br />Proposed Ose: <br />Deec. of Work: <br />T.I. <br />B 43083 SEPA <br />9062SE9EVF.RETT MALL WY #400 <br />PFLUEGER PTRS <br />COP.NERSTONE MORTGnGE <br />OFFICE <br />OFFICE SET JOB SET <br />I�PPROVED FOR PERMIT: DATE_/_/_ BY_— <br />Attach foar (4) copies of plans for proposed work • Draw lo scale and note the (ollowing as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lol <br />• Existing and proposed utilities <br />Pu�lm lYorFs PamO a _ _ <br />fildg Oept � _ <br />Puei¢ Works Fee <br />Tolal Fee S <br />Le55 ApOL FCe Pm0 S <br />Baiancc Uuc S <br />• Centerline ot sGeef <br />• Indicate North <br />• Show any aroposed grading changes <br />• Show measurements <br />LINE <br />?hOne <br />Phone <br />PERMIT COND�TIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 G. <br />2. All work shall 6e pedormed in accordance with this permit and current Ciry of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />`•UBLIC U/OHKS PERMIT <br />N��.REQUIRED <br />BY 71G <br />OATE �2 77 S �=_ <br />Approved for ConstruClion <br />FINAL INSPECTION <br />Approved as Constructed <br />PUBLIC WORKS �EPARTMENT <br />�, 3200 Cedar Street <br />� Everet!, WA 98207 <br />Phone:259-8610 <br />Date <br />Date <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />_ / <br />� <br />� <br />The undersigned owner/applicant hereby agrees to holti and save harm- <br />less the City of Everett from any and all claims for damages. costs, <br />expenses. or causes ot action that may arise because of instali�!ion <br />and maintenance of the improvement or other righl-of-way use hereto <br />applied for and turther agrees lo remove same upon notice from the <br />City and to replar,e public proGeriy damayed thereby. <br />Signature ol Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DA`i'S OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. TI�IS PERMIT MAY BE <br />GANCELLED BY'HE CITY UPON ANY STOPPAGE OF N/0RK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />