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Date��� <br />Application For <br />PUBLIC W�RKS PER�fIiT <br />Print or Type Only <br />Owne� <br />ApplicaM <br />Describe Proposed Work <br />Mailmg Address <br />L ��J4 � "`� <br />Mailing Address <br />n� , - � - <br />ProlectAtldresslitknown) ��14 L.��P(/�(� Ji <br />Attac'i four �4� copies of plans br proposed work - Draw to scale and note the fo'i�wing as applicable: <br />• Property Lines <br />Y Outlinr. and dimensions o� all existing and <br />proposed struttures on ihe lot <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />�_���.� v,��.. v,.�m, p. � <br />eia9 ocpt. s _{! z 6 �_ <br />Pu�l¢'NorksFee 5 <br />Toial Fee <br />�cesRani FcePa�� S <br />Ca'..r.0 Dus $ <br />Phone <br />S 7A R tl ! C/5' 7'v/ <br />• Centerline of street <br />• Indicale Norih <br />• Show any proposed grading changes <br />• Show measurements <br />Phone <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•$81 5. <br />2. All work shall be perlormed m accordance with this permit and current City ol Everett Design and Gonstruction <br />Standards and Specifications. <br />3. Call Loeation Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />���J:- � �t <br />Approved lor Construction <br />`�:.�?,._ �' �, �/'=,,,._.,( <br />r <br />� � ��, , <br />/" `- <br />=�'' ,/� <br />ACKNOWLEDGEh1ENT ��F CONDITIONS <br />The undersigned o��ner/applicant hereby a9rees to hold and save harm- <br />less the City of Everett from any and all claims for dam2ges, cosls, <br />expenses, or causes of action ihat may arise because of installation <br />and main�enance of Ihe improvement or other righbobway use iiereto <br />applied lor and turther agrees to remove same upon notice �rom the <br />Date City:,nd to replace public properry damaged thereby. <br />FINAL INSPECTION Date <br />Approved as Constructed <br />evcrett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. W 4 98201 <br />Phon^: 259-f1Bt 5 <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLV PURSUED TO COMPL[TION. THIS PERMIT MAY BE <br />CANCELLED 8Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJEC� OVER 90 DAYS DURATION. <br />