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Date �' �J • <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />i \ <br />< ,( <br />��-c _C J �'=��;, <br />owner <br />APPlican�.. � <br />i _ <br />Describe Proposed Work _� <br />Project Address (if knownj _ <br />Mailing Address <br />-' ��'c O c3�. <br />CI <br />( ,.°j"�cC_-�' <br />City <br />City <br />Zip <br />PuDhc Works Permil � <br />Bia6�eo�. �^ ✓ �/�:� Lkr�J <br />PuEI¢ WorhS Fee <br />To�al Fee S __ <br />Less AoO� Fee Paia $ <br />Balance Dvc S <br />��( �� �i - d 0,� :� <br />Phone <br />Phone <br />A�tach tour (4) copiec of p�ans for proposed work - Drew �o swle and no�e ihe following as apolicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • I�idicate North <br />proposed sirucWres on ihe lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall he made 24 hrs. in advance - phone 259•88� 5. <br />2. All work shall be perlormed in accordance with ihis permit and current City of Everett Design and Cons�ruction <br />Standards and Specifications. <br />3. Call Location Under3round Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�JU f'�/fj"6/ C <br />��'��C- % � �I� - <br />�f�lii .��� ��c�.E%>iii'- <br />J, .�, <br />�' � 7 � � �` <br />�j L—��c_:'�-`' <br />/ <br />AUP�oved for Constr�ction Date <br />FINAL INSPECTION Date <br />Approved as Consirucled <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98207 <br />Phone: 259-88 7 5 <br />W <br />r <br />� <br />ACKNOWLEDGEMENT OF CONDITIO!JS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims tor damages, costs, <br />expenses, or causes of action ihat may arise because of installation <br />and maintenance of the improvement or other right-obway use herelo <br />applied for and furiher agrees to remove same upon notice from the <br />City and to replace pub�ic property damaged lheieby. <br />Signature of Applicant Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />1f30 DAYS OF DATE PERNIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PFOJECT OVER 90 DA\'O, DURATION. <br />