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Date� <br />Applicat�io� For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Mailinc� AddreSs <br />� Pubh< WorFs Ve�mi� v <br />i r <br />uian. o�oi.. . �_ <br />Puthc \Ymxs Fec <br />TotN Fec g .. <br />Le55 FpPI FCe Pdid S <br />Bd�ln{:f DuC .CJ <br />� CvP/P/� g'rf�Zc 3 3.l 3- y% S 9 <br />City Zip Phone <br />Ciry� Lp Phone <br />Describe Proposed Work l 9('( /�_E� _ <br />Project Address (il known) <br />Atlach four �4) copies ol plans for proposed work - Draw to scale znd note the following as applicable: <br />• Pwperty Lines <br />• Outline 2n�:i dimensions ol all existing antl <br />proposed structures on the lot <br />• Ex�;,ting and proposed utilities <br />• Centerline of slreet <br />• Indiczle Norih <br />• Show any proposed grading changes <br />• Show me2surements <br />PERPA�T CONDITIONS <br />t. All calls (or inspection shall be made 24 hrs. in advance - phone 259-$810. <br />2. All work shall be pertormed in accordance with this permit and current City of Everett Desinn and Construction <br />Standards and Specifications. <br />3. Call Localion Underground Service 48 hrs. before you dig. TOLL FREE NUMBER �-800•�:24•5555. <br />�C�,� � ,��r��ij ,%�,��1. <br />c�� <br />� <br />Approved for Construction <br />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBLICWORKSDEPAFTMENT <br />� 3200 Cedar Street <br />E�.ere�i, WA 98201 <br />Phone:259�861U <br />Date <br />Date <br />,C ��,� i <br />_� (,1� <br />� �_ ,�- �9 � <br />ACKNOWLEDG[MENT OF CONDITIONS <br />W <br />H <br />_ / <br />� <br />� <br />The undersigned owner/apP�icaN hereby agrees to hold anA save harm- <br />less the City ol Everett Irom any and all claims lor damac�es, cosis, <br />expenses, or caus^s of action ihat may arise because of installation <br />and maiMenance of ihe improvement or other righhol-way use hereto <br />applied for and lurther agrees to remove same upon notice irom the <br />Ciry and to replace public property damaged �hereby. <br />Signature ol i�pF�licanl Date <br />WORK AUTHC`:!IZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS GF i)ATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTL`.' PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />