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Datea �`1 �X <br />Application For <br />PUBLIC VilO�RKS PERM�T <br />Priiit or Type Only <br />Mailing <br />Applicart <br />D?scribe Proposed Work <br />Projc,at Address (if known) <br />City <br />Attach tour (q� copies of plans for proposed work - Draw to scale and ��ote ;he rollo�ving a� appl;c2ble: <br />• Proaerty Lines <br />• putline and dimensions of all er.isting and <br />propnsed slrucWres onthe bt <br />• F.xisting and proposed utilities <br />PeLIi�; V/nk.s Permit a <br />F:Cg DePt. n <br />� •�i % _ <br />PuliLc C/nrks �eo <br />Total Feo J� __ <br />Less ApPI. Fee Paid $ <br />?alance Ouc $ <br />• Centerline of street <br />• Indicate Norfh <br />! Sbow any proposed gwding r,hanges <br />• Show measurements <br />� <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection ehall be made 24 hrs. in advance • phone 2S9•&810. <br />2. All worR shall be pertormed in �ccordance with this permit and current C�ry of Everetl Design and Construction <br />Standards and Specificatior.a. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NIIMBER 1-$00•QQQ.5555. <br />%�G'/S'Li� ld2e%S Y�";�iriJ- <br />%-/S d:�Tc-. <br />Approved lor Construction <br />FINAL INSPECTION <br />Approved as Consiructed <br />evere[t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everclt, WA 98201 <br />Phone: 259�8810 <br />/�C�P�'�v� 1�SSc.�is"/> G��,� <br />< �„`� <br />.�� ���?, <br />�CKNUWLEDGEAIENT Of= CONDITIOMS <br />�/ <br />� <br />�LJ <br />♦�� <br />V♦ <br />� <br />a <br />_ The undersigned o�rnedapplicant hereby agrees to hold antl save harm� <br />less the City of Evere�t irom any and all claims for damages, costs. <br />exFenses, or causes of action ihat may arise because ol �nstallation <br />and maintenance of the improvemenl or other righbohway use hereto <br />Date applied for and further ao-ees to remove same upon notice irom ihe <br />City and to replace public property damaged thereby. <br />S�gnature of Applican� Dalc <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERPAIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PUFSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED Bl' THE CITY UPON ANY STOP?AGE OF WORK ON THIS <br />PRCIJECT OVER 90 DAYS DURATION. <br />