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DateJ_���' � <br />ApPlica.ion Fur <br />PU�LIC WOIr�K� 1'ERMaT <br />Print or Type Only <br />hlailing Address <br />M2iliny <br />Describe Proposed'J��.ri <br />Project Address (if known) <br />Attach lour (4) copies of plans for proposed work - Draw to scale and no�e �he lollowifig as applicable: <br />• property Lines <br />• Ou�line and dimensions ef all existing and <br />pro�osed structures on Bie lot <br />• _xi:,iin9 and proposed utilities <br />PEFMIT CC :dGITIONS <br />PcbLc Works Permi� a -�/�� <br />E�IOB� Deo< < �.��1>.lal—.— <br />Pnmic worb �ae � <br />Tolel Fae $ — <br />Le:'�s Appl. Fce Paitl � . <br />BalenceDue $ <br />/ - d /7S` <br />Phone <br />O Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measuremenis <br />1. All ca�ls for inspe�.:tion shall be matle 24 hrs. in advance - phone 259-8$1 $. <br />2. All vor4 shall b� Per(ormed in accordance with this pernLt and current City of Everelt Design and Construclion <br />Standa�ds and S(ecifications. <br />3. Call I.ocahon Uno=rground Service 48 hrs. beiore you dig. TOLL FREE NUMBER 1•800-424•5555. <br />vu0 %�L/.�SL/C 4'p,,�:�'S : �E:�:l��T �c--ny L/i.EFx� <br />Approved tor Construction Date <br />FINAL INSr ECTION <br />Anproved as Constructed <br />everett PUBLIC WOHKS DEPARTMENT <br />� 3200 CeAar Streel <br />Everetr. WA 98201 <br />Phone:259-�815 <br />Date <br />/a/s/�� <br />��� <br />ACKNO�VLEDGEMENi OF CONDITIONS <br />�� <br />� <br />�iA <br />V♦ <br />0 <br />� <br />The undersigned owner/applic:.nt hereby agrees to hold and save harm- <br />less the City of Everett irom any and all claims lor damages, costs, <br />expenses, or causes ot action that may arise because of installotiun <br />and maintenance of ihe improvament or other righbof-way use hereto <br />applied tor and furlher agrees to remove same upon notice from the <br />City and to replace Gublic property damaged thereby. <br />Signatw�e of Applicant Date <br />WOIiK AUTHORIZED 6Y THIS PERMIT MUST BE STARTEC V/1THIN <br />780 UA1':i OF DAl'E PEFMIT Ifi ISSUED AND THEREAFTci+ IS TO <br />BE DIUGENTLY PURSUEO TO COMPLETION. ThIIS PERMIT Id.4Y BE <br />CAIJCELLED BY THE CITY UPON ANY STOPPAGE OF N'ORK ON i HIS <br />PHOJECT OVER 90 DAYS DURATION. <br />