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L <br />Date <br />Applica. . Fcr <br />PIJ�LIC WOFiK� PERMlT <br />r'rint or Type Onfy <br />��c'� ���� - <br />Mailing Addre�s � City <br />� ,5-�.3a - /i� �` �°.A-c <br />Address <br />Describe Proposed VJcrk <br />P�oject Atldress (il known) <br />PuO��r Wo�ws Pprmi� � . <br />Eiidp Oeni • _ <br />vublic Worxs Fee <br />Tolal Fea g <br />�ess R00� Fee PaW 5 <br />Balanco Due 5 <br />� <br />eJ(�.� �3� <br />Zip Phone <br />Attach feur 14) copies of plans for pro;.:.sed work - Draw to scale and not? Ine following as applicable: <br />• Property Lines <br />• Outline and dimensions of all ezisting and <br />proposed structures on Ihe Iot <br />• Existing �nd proposed ulilities <br />PERMIT CONDITIONS <br />• Centerline of street <br />• Indicate North <br />• Show any proposed �radino c:hanges <br />• Show mea5urements <br />7. All calis for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be pertormed in accordance witn this pe�mit and current City ol Everetl Design and Consiruction <br />Stantlards and Specilications. <br />3. Call Localion Underg�ounG Service 48 hrs. before you dig. TOLL FREE NUMBER 7-fi00-424•5555. <br />�C � J'�/� %�.��/il/ �%- ���%'Cii'/'E,! � <br />i <br />for ConStruCtion <br />Date <br />FINAL INSPECTION Date <br />Approved as ConsVucted <br />everett PUBLIC WORKS DEPA(iTMENT <br />� 3200 Cedar Slreet <br />Everett, WA 98201 <br />Phone:259�8875 <br />��� i <br />� ����j,, � [� <br />�,� � <>_ %' <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />Thr, undersiyned owner/applicant hereby agrees to hold and save harm� <br />less Ihe City uf Everett t�om any and all tlaims lo� damac�es, cosis, <br />eapenses, or causes ol action that may arise becaus� ol installation <br />and mai�rienance ol the improvement or olher right�obway use hereto <br />applied for and luriher agrees to remove sart�e upon notice hom the <br />City and to replace puhlic property damaged thereby. <br />Signature ol Applicanl Daie <br />WORK AUTHORIT_eD BY THIS PERMIT MUST BE STARTED WI7HIN <br />120 OAYS OF DATE PERMIT IS ISSUED AND THEflEAF?ER IS 'O <br />BE DILIGENTLY PURSL'ED TO COMPLETION. THIS P�RA11T MAY BE <br />CANCELLED 9Y THE GITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 30 DAYS DURRTION. <br />