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Date� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print �r T•ype Urily <br />-� <br />Owner <br />Applicant Mailing AddrAss <br />Zip <br />Pubiic Works Permit + (��_ <br />Bltlg. Oep�. u _ <br />Pu01ic Works Fce �J o <br />Total Fec $ _ /�; O �� <br />iess ApPL Fcc Paitl $ �_ <br />Balance Due $ �v <br />��07' � <br />o,, P -� � '� `S3 ' �� <br />Phone <br />Describe Proposed Work ���/j��s c��i.��l�r%�%� �r�� S'jo^�C <br />Project Address (if known) <br />Aqach four (4) copies of plans for proposed worl: - Draw to scale and note the following 3s applicable: <br />• Properfy Lines � <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />• Centerline of sVeet <br />• Indica�e North <br />G Show any proposed g•ading changes <br />• Show measurements <br />LINE <br />1. All calls for inspection shall be rtiade 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be performed in accordance wilh this permil and current City of Everett Design and Construction <br />Standards and Specifications. <br />� ��� � 3. Call Localion Underg�ound Service 48 hrs. before you dig. TOLL FREE NUMBER 1$n0-4'?4•5555. <br />N � <br />1 /�' <br />/�Fp�'� � �c-2�cc - �i � h//G//.._ �Q�-fx�/.E'c� o� .Sc��Tiy <br />i <br />I�° l'� �/ ' <br />�/�0���'. ' / �/1%��� //1'�J`i /9<G/�T�o/1� �y ���io . <br />/ � <br />.� C'/� ��(/.E�r-�'i /�r�/e �J�'/!�' G�/��/ [�i�j�G,l_� <br />cci/-r�----�i �'v.P��G'C�Ti�'s� �cr.yY.S>`.�`ueT�o O-�I� <br />L OU.i'�-=i�' ,�'i�JG'.�` /�c�f ct�- <br />� <br />_��� � /�- � as. <br />Ap 4eG tor Co truc ' Date <br />FINAL INSPECTIOfJ <br />Approved as Constructed <br />everett PU�:LIC WORKS DEPARTMENT <br />� 320c CeCar Sireet <br />Evere�t, WA 98207 <br />Phonc: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />I•1 <br />�. J <br />The undersignetl owner/applicant hereby agrees to hold and save harm� <br />less ihe Cily of Everelt from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance cf the improvement or other righ4of-way use hereto <br />applied for and furiher aqrees to remove same upon notice from the <br />Cily and to replace public pror,erry damaged thereby. <br />/�i% // <br />/ `' i��i'��/� /.�-�'y —c� � <br />' natur f Appli ant � Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHII� <br />180 DAYS OF DATE PEPMIT IS ISSUED AND THEREAFTER IS TU <br />BE DILIGEIJTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CAI�CtLLED BY THE CITY UPON ANY STOPPA�iE OF WORK ON THIS <br />PROJECT OVER 90 DAl'S DUF�TION. <br />