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Date a�o � ``7'� ��J2�tU`� <br />Application For <br />PUBLIC W6RKS PERMIT <br />Print or Type Only <br />�� <br />Describe Proposed Work <br />Project Address �if known) —�-���L <br />✓ <br />' �, � F�cPE <br />Ciry Zip <br />Ci.ry Zip <br />Atlach lour (4) copies of plans for proposed work - Draw to scale and note the following as apphcable: <br />• Proper�y Lines <br />• Outline and dimensions of all existiny and <br />proposed struclures on the lol <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />PubLCWorhsPermu+ �V �/� <br />amo� oeo�- • <br />Pu�licWalk9Fee 5 <br />Toial Fee <br />Less PO�� Fee Pa� 5�- <br />BaianceDuc S a�� <br />• Centerline of Street <br />• Indicale North <br />• Sh�w any proposed grading changes <br />• Show measurements <br />1. All calis for inspecllon shall be m�de 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be perlormed in accordance wilh this permit and current City of Everett Design and Consiruclion <br />S�andards and Specilications. <br />3. Call Location Underground Servi�:e 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424-5555. <br />f"Gvc,� ,�r .9cc�-y r,✓,�2s�-cr,o,�/ %o B,= c�:,- ���c.e <br />�Is .t�%�c;E'�� ay 7i✓E ,2B�ic cda2,�-s I,��;�,�cro.e. <br />Apuroved as Construded <br />������� PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Eve�etL WA 98201 <br />Phone:259�8815 <br />ACKNOWLEDGEMENT Of CONDITIONS <br />ihe undersigned owner/applicant hereby a9rees to hold and save harm- <br />less ihe Ciry of Everett from any and all claims tor damages, costs, <br />expenses, or causes of action that may arise because ol installation <br />and maintenance of the improvement or other righFol-way use nereto <br />applied for and iwther agrees to remove same upon notice irom the <br />City and to replace public property damaged thereby. <br />Signature <br />Date <br />WORK AUTHOFIZED BY THIS PERMIT MUST BE STARTED WITFIIN <br />180 DAYS OF �ATE PERM11IT IS ISSUED AND THEREAFTEF IS TO <br />BE DILI6ENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />GANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />FROJECT OVER 90 DAYS DURATION. __ <br />