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Date_-���"% <br />Application For <br />PUBLIC WORKS PERI�IIIT <br />Print or Type Only <br />o�•��P� <br />ApUlicant <br />Describe Proposed Work <br />Prolect Address (if known) <br />Mailing Address <br />Mailiny Address <br />c��v <br />Ciry <br />-�..,._ �:��,.•. �,:,��„� , <br />E31C9 DepL e _ <br />Pubf.c WorkS FCe <br />To�nl Fco S <br />Less Appl Feu i aiC $ <br />Balance Ouo �u <br />= 35 <br />Zi� P <br />Zip Phone <br />Attach four (4) conies of plans for pr000sed work - Draw to scale end note the following as applicable: <br />• Property Lines <br />• Outline ard dimensions of all existing and <br />pioposed siructures on ihe lot <br />O Existing and proposeh utilities <br />PERMIT CONDITIONS <br />• Centerline of slreet <br />• Indicate North <br />• Show any proposed gradinc� changes <br />• Show measurements <br />�Iq <br />1. All calls tor inspeclion shall be made 24 hrs. in advance � phone 259•$81 5. <br />2. AI! work shall be performed in accordance with this per�nit and current City of Everett Desi9n and Construction <br />Slandards and Specifiwtions. <br />3. Call Location Under�round Service 4S hrs. before you dig. 70LL FREE NUMDER 1•800•424•5555. <br />/ � /�� . � �;�.o `) � 7.-.� - <br />(�ci �G.����C t� �_ _i��� /-������T ���_,�_r�i��•> <br />Approved tor Constriiction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUB�IC WORKS DEPARTMENT <br />� � 3200 Cedar Streel <br />Everetl, WA 98201 <br />Phonc: 259-8�15 <br />i <br />y�7 �/� —i <br />�/��. <br />n. <br />ACKNOWLEDGEF,:C-NT OF CONDITIONS <br />The undersigned owner/�pplicar� h��zby agrees to I�old antl save harm- <br />less ihe City of Everett Irom ai�y and all claims tor damages, cos15, <br />expenses, or causes of ection that may arise be::ause of installation <br />and maintenance ol the improvement or other ri9ht�obway use nereto <br />applied for and furthei a9recs to remov� same upon notice Irom Ihe <br />City and to renlace public property damayed thereby. <br />Signa�ure ol AppliCan� Da�e <br />WORfC AUTHORIZED BY THIS PERMIT MUST E3[ STARTED WITHIN <br />78U DF�YS OF D�TE PERMIT IS ISSUED AND THEREAFTEf� IS TO <br />BE DILIGCNTLY PURSUED TO COMPLETION. THIS PEP.�✓!IT MAY BE <br />Cl.NCELLGD BY THE CITY UPO�' ANY STOPPAGE OF 1NORK ON THIS <br />PROJEi,T OV[R JO DAYS DURATION. <br />