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�s�,��} IZ -ZB-�f <br />Date�.�} 1 V <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�t <br />Describe Proposed Work <br />Project Address (il known) <br />Mailing Address <br />City <br />Zip <br />Attach four (4) copies of plans lor proposed work - Draw to scaie antl no�e Ihe lollowing as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed siructures on the lot <br />• Existing 2nd proposed utilities <br />i <br />/ I <br />� //Z � <br />Publ¢ Wo�k. Pormi� • n i <br />O�aB. OeDt. s ��� � i <br />PWh[ WorksFee �� <br />Total Fee $ � <br />Less Aool Fee Paitl � ^� <br />BalanceDue 5 G� <br />• Centerline ot street <br />• Indicale North <br />• Show any proposed grading changes <br />• SFow measurements <br />� <br />a o. <br />Phone <br />FERMI"f CPNDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-8$10. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800-424-5555. <br />�i1�1 ;� � !z1 9� <br />ApProved for Constru ti � Date <br />�� —/ J — ii <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />everetl PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everet�, WA 98201 <br />, Phone:259�8810 <br />one <br />ACKNOWt.EDGEMENT OF CONDITIUNS <br />W <br />H <br />M / <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersic�ned owner'applicant hereby agrees to hold and ::ave harm- <br />less the City of Everetl from any and all claims for damages, costs. <br />expenses, or �auses of action that may arise because of in5tallalion <br />and r�aintenance ol ihe improv ment or other righFof-way use hereto <br />applied tor and further agree lo remove e2me ���on notice from ihe <br />City and to re� public pr perf��amaged theieby. <br />re <br />uate <br />WORK AUTHK7RIZE� BV THISPERMi�i"MUST BE STARTED WITHIN I <br />180 DAYS OF DATE PERMIT I:i ISSUED AND THEREAFTER IS TO i <br />BE DILIGENTL'! PURSUED TO CG6iPLETION. THIS PERMIT MAV l3G i <br />CANCELLED BY TFIE CITY UPON ANY STOPPAGE OF WORK ON THiS <br />PPOJECT OVER 90 DAYS DURATION. <br />