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Date �� �` � <br />APplication For <br />PUBLlC ViJORKS PERMIT <br />Print or Type Only <br />Mailing <br />LC <br />Pubh[VlorksPcrmR• '�` ��� _ <br />91d9. �eot . <br />Pa01ic Works Foe 5 <br />Tclal Fce <br />less AOD� Fee PaiO $ <br />Balancc �ue $ �n �����/� <br />t�ppucan[ rnawrg qtldress Gity Zip Phone <br />Project Address (if known� <br />Atlach tour (4) copies of plans for proposed work - Draw to scale and nole the (ollowing as applicable: <br />• noperty Lines O Centerline of street <br />• Outline and dimensions ot all existing and • Indicate North <br />proposed slructures on thr, lot • Show any proposed grading changes <br />• Exisling and proposed utili�ies • Show measurements <br />PERMIT COIJDITIONS <br />1. All calls foi inspection shall be made 24 hrs. in aAvance - phone 2S9•Li81 $. <br />2. Ali work shai! `_+e performed in ac�ordance with ihis permit anA wrrent City of Fvereit Design and Construction <br />Slandards and Specifications. <br />3. Call Location Underground Sen�ice 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424•5555. <br />�, /.E'EES �.eF TO BC �EMn✓2�0 O•(l �.�T 5�o O�t/:Gy, <br />S. lJ�i�` _�f/rJS �/.'�7 EcS 7`HriT f�.FE i��Z9.C't>C���S i5'�i�E'LG <br />� 9ccEi;.' T�EES �'.,c�U Sy;'�-�.�'S':,-'�i_E %G� /.�'�--i,��i�t�. <br />Approvetl as GOnstruCtetl <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Eoerett, WA 98207 <br />Pr:.me: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />The undersigned owner/applicant hcreby agrees to hold and save harm� <br />less the City of Everell irom any and all claims for damages, costs, <br />expenszs, or causes of ac�ion ihat may arise because of installation <br />and maintenance of the improvement or other righbof�w2y use nereto <br />applied for and further agrees to remove 52me upon notice from lhe <br />City and to repiace public property Cama9ed thereby. <br />Signature o�plicant � <br />WORK AUTHOfll7_ED :i' T IS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF �ATE PCRMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON 4NY STOPPAGE OF \NORK ON THIS <br />PROJECT OV��R 90 DAYS DURATION. <br />