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oete_��y � <br />Applica;lon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Qwner <br />Mailing <br />� <br />PUEIic Works Perm�l_ • <br />�(l�eltlp. Ocpt. e [1_7 <br />P�Olic WorMn Fae s <br />Total Gee <br />Leas ApO� Fea PeIC S�- - <br />Balance O�e <br />�\R�U�I'A-��T ���3 3 sJ � <br />c;c ' Zip Phone <br />Lip rnone <br />Describe Proposed Work � �+ — <br />Project Address �il known) <br />Attach four (4) copies of plans tor proposed work • Draw to scale and note the lollowing as applicable: <br />• Property Lines • Centerline oi street <br />• Outline and dimensions ot all existing and • Indicate North <br />qroposed structures on the lot • Show any prop�sed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />7. All calls for inspection shall be made 24 hrs in advance - phone 259•881 5. <br />2. All work shall be pertormed in accordance with this permit and current City ol Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Servico 4B hrs. before you dig. TOLL FREE NUMBER 1-500•424-5555. <br />� �`` <br />P�� � <br />� <br />�-r�-��-�an ? <br />Approved for Construction Date <br />FINALINSPECTION <br />Approved as Constructed <br />everett PUBLIC WOHKS DEPAR7'MENT <br />� 3200 Cedar Sireet <br />Everet6 WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGLDAENT OF CONDITICNS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett irom any and all claims for damac�es, costs, <br />expenses, or causes of actinn that may arise because of inslallation <br />and maintenance of Ihe imGrovement or other right-of-way use h=reto <br />applied for and furiher agrees to remove same upon nolice �rom the <br />City and to replace public property damaged thereby. <br />Dale — <br />Signature ol Applic: -� Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEii IS TO <br />8E DILIGENTLV PURSUED TO COM?LETION. THIF. PERMIT MAY BE <br />C.INCELLED BY THE CIT`f UPON ANY STOPPAGE OF WORK ON THIS <br />PP.OJEI:T OVER 50 DAYS DURATION. <br />