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Date�%��� <br />Application For <br />PUBLlC WQRKS PERNlIT <br />Print or Type Only <br />�/? LM � <br />Applicant <br />Describe Proposed Work <br />Project Address (if known) <br />.-� <br />Public Works Parmil a <br />eie9�oeo�.+ � �/c,�� <br />Pu�lit Workg Feo <br />Total Fee $ <br />Less Appl. Fee PaiE �u <br />!'alancc Ove <br />■�� <br />. ,7T.LL:f <br />Mailinn Address City Zip Phona <br />Atlach four (4) copies ol pla�s for proposetl work - Draw to scale and note ihe following as applicable: <br />• Property Lines <br />• Outline and dimensions ot all existing and <br />proposed siructures on the lol <br />• Exisling and prouosed ut!lities <br />• Centedine of s!reel <br />• Indicate Norih <br />• Show any proposed 9ratlin� changes <br />• Show measurements <br />PcRM1T CONDITIONS <br />t. All calls (or inspection shall be made 24 hrs. in advance • Chone 255-5810. <br />2. All work shall be performed in accordance w�.h this permit and current City of Everett Design and Constroction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. 6etore you dig. TOLL FREE NUMBER 1-800•424-5555. <br />/f/� f�oB�c <br />�2GL'�Oi�ti('s <br />G/O��' PF,FiH/T �P�j <br />%i�%r /S �A,�/ f.r�zTi.vG j>,eil��'fv�9y <br />���BA <br />. � <br />Appro+ed lor Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />e��ere[t PUBLIC WORKS DEPARTMENT <br />� 3200 CedarStreet <br />Everelt, WA 98201 <br />Phone:259�881G <br />ACKNOWLEDGEMENi OFCONDITIONS <br />W <br />H <br />� <br />N <br />� <br />� <br />The undersi�ned ownedapplicant hereby agrees to hold and save harm- <br />less the City ol Everett irom any and all claims for damages, cosis, <br />expenses, or causes of action ihat may arise because of installalion <br />and maintenance of ihe improvement or othcr righl-ohway use herelo <br />applied br and fur�her agrees lo remove same upon notice Irom the <br />City and to replace public property tlamaged thereby. <br />Signa��.�re ol Applicant Datc <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STAATED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMF'LETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOFK ON THIS <br />PROJECT �)VER 90 DAYS DURATION. <br />