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Date�,%g7 <br />Application For <br />PUBLIG M/4RKS PEF�MIT <br />Print or Type Only <br />� <br />�pplicant <br />Describe Proposed Work <br />Prolect Address (if known) <br />Adtlfe55 <br />Ci�y <br />Zip <br />Zip <br />Attach tour (4) copies ot plans lor proposed work - Draw to scale and note the followiny as applica6le: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />Putllc Wotks Permit sc `�" �c ��]j <br />BItl9. DeVC i n 7�/ � A O"7 <br />PublicWorksFee � <br />To�al Fao <br />Less AOo� Fan F..iO � n O nL� — <br />Balence Oue � _°" <br />• Centerline of atreet <br />• Indicate North <br />• Show s iy proposed grading chanc�es <br />• Show measurements <br />Phone <br />1. All calls for inspection si�:ll be made 24 hrs. in advance • phone 259•881 5. <br />2. All work shall be performetl 'n accordance wi�h ihis permit and current City of Eve�e�t Design and Conctruction <br />S�andards and Speciticatiors. <br />3. Caf Location Undergrounr� Service 48 hrs. belore you dig. TOLL FREE NUMEEH 1-800•d24-5555. <br />FIM:L INSPEGTION <br />Approved as Constructed <br />e.verett PUBI_IC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-887 5 <br />0�/�6i 8 � 4:2C�f'M MURN4?:'.1 <br />/ <br />(i0002'ED3 <br />t,��G k81.OD <br />E: ShCH 4�1.50 <br />D�i�iVFWr�{'� 4�O.OD <br />ACKNOWLEDGENfENr oF4�Sbb1��lONS <br />W <br />H <br />�w <br />_I <br />Z <br />O <br />The undersiyned owner/applican� hereby agrees tc hold and save harm� <br />less the City of Everett trom any znd all claims for damages. costs, <br />expenses, or causes o! action that may arise because of installation <br />� a,U ��, and maintenance of the improvement or other righ�-of-way use hereto <br />D te applied for and lurther agrees to remove same upon notice irom the <br />Ciry and to replace public properq� damaged thereby. <br />7 �Da et ,����. � ,/ (�-�!�`�"" � — �--� <br />Signature of plicant Date <br />WORK AUTH�RIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY rURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY 1 HE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />