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Date� <br />Application For <br />P���iC WORK� PERMIT <br />Print or Type Only <br />Applican� <br />Describe Proposed Work <br />Project Address (if known) <br />Mailing A <br />Pu�Lc 1VarFs permil + T1-- <br />pNg.DCOt+ �� �Q- �OT <br />PuUbc WOrkS FM <br />Told' Fec S <br />lesi 40p1 FCe VaN S <br />Balance Duc S <br />Z�P Phone <br />Atlach tour �4'i copies ol plans loi proposed work - Draw to scale and note ihe lollowing as apPlicable: <br />• Property Lines <br />• OWline and d�mensions of all existing and <br />proposed structures on ihe lot <br />• Existing and Groposed utililies <br />o Cenlerline n( slreel <br />• Indicate North <br />• Show any proposedc�rading cnanges <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calie (or inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be peAormed in accordance with this permit and current City of Fverett Design and Construction <br />Stantlards and Specifica�ions. <br />3. Call Location Underground Service 4R hrs. before you �i9. TOLL FREE NUMBER 1•$00•424•5555. <br />O / <br />'.���'�� �v��y� �' ti� ,� - ��-� <p� <br />2�z� � i <br />�� � �� �� - <br />� .,,%� �' <br />Approved lor Construction <br />FINAL INSPECTION Date <br />Apprcved as Constructed <br />cvcrctt PUBLIC WORKS DEPARTPdE�T <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phona 253-A810 <br />ACKNOWLE�GEMENT OF CGGaUITIONS <br />� <br />� <br />fhe undersigned owner/applicant hereby agrees to hold anA save harm� <br />less the City of Everett from any and al! Claims for dama�es. costs, <br />expenses. or causes of action that may arise because ol inSt:�IlaGon <br />and maintenance ol Ihe improvemant or other righl-of�way use hereto <br />applicd for and furthar a�rces to remove same upon notir,e I�om thr <br />City and to replace put�lic pronerty dama9ed the�eby. <br />Si9nature of Applic:inl Da�e <br />V/ORK AUTHORIZCD BY THIS PERMIT MUST BE STARI�ED WITHIN <br />180 DAYS UF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY FURSU[D TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON AN7 STOPPNGE OF WORK ON THiS <br />PROJECT OVER 90 DAYS DURATION. <br />