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Date�����0 ~ <br />Application For <br />PUBLI� WORK� PERMI� <br />Print or Type Only <br />Describe Proposed Work <br />Prolect Adc;ess (il known) <br />PUEIIc Wmks Perm[lt �a <br />BIEO� �ept. n �; ? �a <br />Publi<Kbrke Fae <br />To�al Fee $ <br />Lasa AppL F: e VaiA � <br />Belance Oue <br />�53 — %(o.! ' <br />Z�P Phone <br />�/ / ([ / i � <br />Mailing qddress City Zip Phone <br />_1��Ld�>„�. <br />Atlach four (4) copies of plans for proposed work • Draw to scale ard note the (ollowin� as applicable: <br />• !'roperty Lines <br />• Outli��e and dimensions ot all existi�ig and <br />Proposed structures on the lot <br />• Existing and proposed utililies <br />PERMIT CONDITIONS <br />• Centerline of street <br />• Indicate No•�h <br />• Show any proposed grading changes <br />• Show measurements <br />�I. All calls lor inspec�ion shall be made 24 hra in advance - phone 259•8$1 5. <br />2. All work shall be pertormed in acr,ordance with ihis permit and current Ciry of Everett Design and Construction <br />Standarcls and Specifications. <br />3. Call Location Underground Service 48 hrs. belore y�u dig. TOLL FREE NUMBER 1•800•424-5555. <br />�C,v PE.C'in.% /Gb7' .c�'c---qr.�%er�o <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 CedarStreet <br />Everett, WA 98201 <br />Phone: 259-8815 <br />�/z�8� <br />� ce'f�✓> <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />�w <br />7S <br />0 <br />a <br />The undersigned owneUapplicsnt hereby agrees to hold and save harm- <br />less the Ciry of Everet� trom any and all claims for damages, costs, <br />expenses, or causes of action ihat may arise because of installation <br />and maintenance ot �lie improvement or other righboFway use hereto <br />applied tor and further agrees to remove same upon notice trom the <br />City and to replace public property damaged ihereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED 8Y THIS PERMIT MUST 6E STARTED WITHIN <br />180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PEI7MIT NAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WGRK ON THIS <br />PROJECT OVER 90 DAYS CUFATION. <br />