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Date��$ �J <br />Application For <br />PUBLIC WURKS PERMIT <br />Print or Type Only <br />Mail�ng <br />�a �osTir�c __�_;;.—; � <br />Mailing Addre�s <br />Descrihe Proposra Work <br />City <br />� <br />Projecl Address (il known) ��'���' � r�-�� � �' "� ' ` <br />Attach �our (4) copies of plans lor propused work � Draw to scale and note the lollowing as apPlicable: <br />• Properry Lines <br />• Outline and dimensions of all existing and <br />proposetl structures an the Ict <br />• Ex'sting and proposed utilities <br />P�ALf VlorFS P�tm-• v �� �� �� � <br />p � <br />5iae oeai . __�l-�.�rZ_ <br />FlubLc WaMs Fec <br />Total FPe 5 --. . <br />Less AnO� Feo Pa�O 5 _ <br />Balonco Oue � ��� <br />• Centerline af street <br />• Intlicate North <br />• Show any proposed grading change, <br />• Show measurements <br />Phone <br />PERMIT CONOITIONS <br />t. All calls for inspection shall be made 24 hrs. in advance- phone 259•8810. <br />2. All vior4 shall be peAormed in accordance with this permit and current City oF Everetl Desig� and Constructlon <br />Standards and Specifications. <br />3. Call �ocation Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-500•424-5555. <br />4. Gu�6,c-iU�'f�lt �Na S� R k1AL�C At'L �IJsT7�c�L=S� A^ll� �� <br />��-r Cef� C_c:ti1 O�TiCnJ ��i � i 1-+ c`� i �zc=AK.`, —/\iri�L i c n,�i r; tM�- <br />iN`->�:��� lJ�.� �,_;���.c,u�."�z,s ����wA�,c. lr= �R-��r_a.cc <br />�' C, c.�'i?\, . <br />/ �� (� <br />-�-� l � \ ���1 � �-� � 2- - �j _ �;'� <br />Approved lor nstructiun , , Date <br />`/ / � � <br />FINA IN TION � <br />Approved as Constructed <br />everett PUOLIC WORKS DE°ARTMENT <br />� 3200 Cedar Street <br />Everett, WA 99201 <br />Phone:259�8810 <br />ACKNOWLEDGEMENT OF CONDITIOIJS <br />� <br />�/ <br />�r/� <br />V� <br />Q <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less ihe City of Everett Irom any and all claims for damzges, costs. <br />expenses, or causes of action that may arise because of installa�ion <br />and maintenance of the improvement or other righhol�way use hereto <br />applied lor and luriher ayrees to remove same upon notice Irom the <br />Ciry tc replace public p�operty damaged ihereby. <br />s� � �,�'��' .�� �-zz -.o <br />Signat re of Applicani Date <br />WORK AUTHORILED BY THIS 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 9E <br />CANCEILED BY THE CITY UPON ANY STOPPAGE OF WORK CN THIS <br />PROJECT OVER 90 DAYS DURATION. <br />