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�� � <br />Date!/ y .�> <br />Application For <br />PU�LI� WQRKS PERMIT <br />Print or Type Only <br />� <br />�z3 t r <br />City <br />Pu^M1c vJorM� Ppermi� a <br />�1a9- Da�l n O'��� $�J' OS� <br />T <br />Pu�i�cWorksFee 5 <br />Totel Fea <br />Lesa Appl Feo Paid � <br />Balancc Due 5 <br />�/��D/ �S�-3y/ 3 <br />PhOne <br />cJGG I %� '� <br />Applicant Mailing Address City Zip Phore <br />Describe Prnposed Work vY_L.[ ' ' - - - --- -- <br />V__��'�__�.�#�('. � ' <br />/ � <br />Project Adtlress (if known) _==�� �� � �---���,��s� <br />Attach four (4) copies of plans for proposed work - Draw lo scale and note ihe following as applicable: <br />• Froperty Lines • Centerline of sireet <br />• Outline and dim�nsions of all eKisting and 9 Indicate North <br />proposed s�r�ctwes on �he bt • Shcw any proposed 9radicg changes <br />• Existing and proposed utilities O Show measurements <br />PERMIT CONDITIONS <br />1. 411 calls for inspeclion shall be made 24 hrs. in advance - phone 259•881 5. <br />2. .�II work shall Le fertormed in accordance with this permit and current City of Everett Design and Cons�ruction <br />Standards and SF�'cifications. <br />3. Calt Location Underground Scrvice 4d hrs. be(ore you dig TOLL FREE NUMBER 1-400•424•5555. <br />/G li' /Gc'�-'i�G ! c � L!iJ.�'�S �l",c=i ��iT <br />� <br />�t�;;��,/,� F> <br />Approvedfor <br />L�����- <br />/ �� -S."-> _� <br />ACKNOINLEDGEMENT OF COIJDITIONS <br />.' <br />ihe undersiyned owner/apUlicant hereby agrees to hold and save harm- <br />--- less lhe City o( Everelt trom any and all claims lor damages, cosis, <br />expenses, or causes of action ihat may arise because ot installation <br />and mainlenance of the improvement or other right-of�way use hereto <br />applied for and turther agrees Io remove same upon notice (rom the <br />Date City and lo replace public properry dama9ed thereby. <br />FINAL INSPECTION Dale <br />;�.pprcved as Conslructed <br />ecerett PUBLIC WORKS DEPAHTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone:259-�A15 <br />Sic�nature <br />Date <br />WOFK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UI'ON ANY STOPPAGE OF WORK ON THIS <br />PROJEGT OVER 90 DAYS DURATION. <br />