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I �� � <br />.��,� <br />Date��, a � u 1 <br />AppliCation For <br />PUSLiC WORKS PERMIT <br />Print or Type Only <br />ow�e� <br />DeScrine Proposed WOrk <br />Prolect Address (il known) <br />Mailing <br />� <br />Ciry <br />�'vo�i: WoiNs Prime . ✓ �c���� <br />a� l / <br />Licg oeo�. • �� <br />Puor,c Worxs Fee <br />rotalFee S <br />Less AOP� Fee PaiO 5 '/ <br />0alance Oue $ � T� �� <br />� , , �� - <br />FI l �:S% - y0� <br />Zip Phone <br />�r �/��� 35�3-��>� <br />2ip Phone <br />Attach four (4) copies of plans fur proposed work - Draw to scale and note the lollowing as aPPiicaU�e: <br />• Property Lines • Centerline of street <br />! Outline and dimensions of all existing and • Indicate North <br />proposed siruc;ures on the lot • Show any proposed 9rading changes <br />• Ezisting and proposed uti� :ies • Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 2$9•881 5. <br />2. All work shal! be pertormed in accordance with this permit and current City ol [vered Desi�n antl Construction <br />Standards and Specifications. <br />3. Call Location Untlerground Service 48 hrs. hefore you dig. TOLL FREE NUMBER 1•80U•424•5555. <br />/• /� �i� �'O//S>_/'G�'C'/ �� ��.E.' fi�% %�O:'��l� <br />�Ld�t/S �.9TL'O // . i�'- ��� <br />C__;i���c.a.� ��/.��-$_ <br />Approved lor G nsiruction � Date <br />� 3 � -�"� <br />I��� Date <br />Approved as Constructed <br />i.�.���q PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Evcret�. WA 98201 <br />Phone: 259�8815 <br />ACKNOI'JLEDGEMENT OF CONDITIONS <br />W <br />� <br />� / <br />� <br />O <br />The undersi9ned owner/apPlicanl herehy ayrees to hold and save harm� <br />less the City of Everett Irom any and all claims lor damages, costs. <br />expr,nses. or causes of action Ihat may arise because of installa�ion <br />and maintenance of the improvement or other right-oFway use hereto <br />applied lor and furiher agrees to remove same upon notice frem the <br />City and lo replace publjc propQc! damac�ed ihereby. <br />� <br />� U�Z <br />Signa�ure ol Applicant Date <br />WOFK AUTHORI�ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DIIIGENTLY PURSUED TO C061PLETION. THIS PERMIT MAY BF <br />CANCELLED �l' THE CITY UPON AlJY STOPPAGE OF WOPK ON r�{�c <br />PROJECT OVeF� 90 DN'S DURATION. <br />