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Date �L�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />i � <br />Mailing Address <br />Pu�Lc Wprks Permit � _ <br />BIEry.Deo�• �'3_ /aa,�,6 <br />FUEiic Woi.e Fne a <br />Totnl Fea <br />Lesa ApO� Fee GeiE � <br />Balence Cuu S <br />Z�P Phone <br />S.�iF <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work QQ <br />Projec� A;ldress (if known) <br />I d4T <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions oF all existing and • Indicate North <br />propesed Structures on the lot • Show any proposed grading changes <br />• Existing anA proposed utilities • Sho�v measurements <br />PEPoMIT CONDITiONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phor�e 259•881 5. <br />2. All work shall be pnrformed in accordance with this permil and current Cily of Everetl flesign and Construction <br />Standards and Specifications. <br />3. Call Locatiun Under9round Service 48 his. before you d�p. TOLL FREE NUMBER 1•800•424•5555. <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as COnstruCted <br />everett PUBLIC YJORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everetl, WA 98201 <br />Phone:259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />� <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />less the City ol Everett imm �ny and all claims for damages, costs, <br />expenses, or causes of aN�on tha� mey arise because of installation <br />and malntenance ol ihe improvemenl or other right•obway use hereto <br />applied for and tierlher agrees to remove same upon nolice Irom the <br />Ciry and to replace public property damaged thereby. <br />Signa�ure of Applitani Date <br />WORK AUTHOfiIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DAT[ PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO CGMPLETION. THIS PENMIT MAY BE <br />CANCELI.ED BY THE CITY UPON ANY STOPPAGE OF WORK ON TFiI� <br />PROJECT OVER 90 DAYS DURATION. <br />H <br />H <br />n <br />b: <br />