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Date� -,LI –E��� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />f <br />�._,�,-; �,._1�_I_ L� <br />.;_�-, <br />ddress <br />Pu���c Works Permil � __� <br />Bldg Dep:. s . <br />Publ¢WorksFee � <br />$ -,: <br />Tola� Fce ' — <br />L¢55 ROOL F¢B Pditl $ � <br />BelenceUue $ ��� <br />I, ,_.. '_ �� ) ��"�� • � I� ; � � � �� 1 ' � Q Z� �3 E "7 � <br />Zip <br />_�"i�-Ll,�ti _ <br />Applicant Mailing Address City Zip <br />t <br />DescribeProPosedWork ,�.-. `--C�F�-�`-lt-tc-�T�. ('�.\�,\i) ��:.r-� �"'r--�4�•.•I A- C._ %�L.�._F� <br />�` <-t �� - >> /'•,L ✓ i � " 1 r.� i - — <br />-t- <br />Project Address (i( kno�.vn) - '�--� - <br />Attach four (4) copies of plans for proposed work - Oraw to scale and nole the folloviing as applica6le: <br />• Property Lines <br />• OutlinE and dimensions ol all existing and <br />proposed structures on the lol � <br />• Existing and proposed util�ties <br />• Centerline ol street <br />• Indicale Norlh <br />• Show any proposed c�rac inq r.hangcs <br />• Show measurements <br />FFR"11T t:ONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - Phone 259-$81 5. <br />2, All work shall be pe�formed in accordance with this permit and current City ol Everett Design and ConsVuction <br />Standards and Specilica�ior,s. <br />3. Call Lowtion Underground Service 48 hrs. 6efo�e you diy. TCi.I FREE NUME3ER 1-800•424•$555. <br />Approv� d ur C�nstruction � � Date <br />l� <br />'�G�'%y��� �f� — <br />FINAL PEC?ION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone:259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undeisic�ned ownedapplicant hereby agrees to hold and save harm- <br />less lhe Ci�y ot Everett hom any and all claims lor damages, cosis, <br />expenses. or causes ol ac�ion Ihat may arise because ot installation <br />and maintenance ol the improvement or o�her rigM-oFway use hereto <br />applied lor and lurther agrees to remove same uoon nolice from the <br />Cit•; snd to c^rla..c public i,rcFcri� dacag� tha�aty. <br />�--�. ��'`. <br />Signature ot Applicant T` Date <br />WORK AUTHORIZED BY TkiIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIG[NTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PR(�JECT OVER 90 DAYS DURATION. <br />