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Date �d �� ��-� <br />Application For <br />PUBLIG WORKS PERMIT <br />Print or Type Only <br />�� <br />Mailing Address <br />l� <br />��1,- t'�J C'1'ze� <br />City Zip <br />cay <br />Describe Proposed Work —�OZ(� �ONS % L>UC'j�i�] �q2A�.�— <br />Project Address (if known) <br />Jublic Works Permil n � ��°'�� <br />eiee. nno�. r �3� � S� 3 <br />Pubtic Works Fee �-� ^ l �� <br />Totalfee �^'" <br />Less AppL Fee Peitl S ^ �^�1 <br />BalencaDuo $ �"`� • �V <br />Altach Four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Cenierline of street <br />• Outl!ne and dimensions of all existing and i Indicate Norlh <br />prof�osed siruc!ures on ihe lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />for <br />„2S� �F17 <br />Phune <br />P[RNIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />?. All worrc shall 6e performed in accordance with this permit and curren� City of EvereU Design and Consiruc�ion <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. befor= you dig. TOLL FREE NUMBER 1•800•424-5555. <br />� <br />pproved as Constructed <br />II everet[ PUBLIC WORKS DEPARTMENT <br />I 3200 Cedar Street <br />� � Everelt, WA 98201 <br />� Phone:259-6815 <br />� <br />0 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owncr/applicant hereby agrees to hold ar.d ^,ave harm- <br />less the Ciry of Everett from any and all claims for tlamages, cosis, <br />� ezpenses, or causes of action that may arise because ol installation <br />F and mainlenance of the improvement or other right-of-way use hereto <br />applied �or and further agrees fo remove same upon notice from the <br />Date City and to replace pu6lic propert�� damaged thereby. <br />Date ����� r `, �J / � <br />Signatr.re of Applicant Date <br />WORK AUTHORIZED 8I THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PUFSUED TO COMPLETION. TI;IS PFFMIT MAY BE <br />CANCELLED BYTHE CITY UPON ANY STOPPAGE OF WGRK ON THIS <br />PROJECT OVEFi 90 DAYS DURATION. <br />4 .'. <br />� <br />H <br />H <br />n <br />Ctl <br />H H <br />H '*J <br />� � <br />� <br />O � <br />� <br />�H <br />z <br />��i <br />H H <br />� � <br />O � <br />� H <br />� <br />� <br />� <br />. � <br />� <br />� <br />� <br />H <br />� <br />y <br />H <br />(7 <br />ia <br />