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/ �. <br />Date� , _i <br />Applicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�'� ;:�':� <br />Puonc Work� Permii � _lt��_ <br />eieo� osoi. • <br />PUCIK Work�Faa : �,[9 Q <br />Tol�l F�a / !J <br />La�� AoO� Fee PsiO i=7%-J�..�.� <br />G.. ��i <br />B�I�nce Due i c 4C.�— <br />c,y.. ; � <br />, "�l� �� <br />Applitant Mailing Address Cily Zip Phone <br />i <br />Descnbe ProPosed Work � � 1 ` .: �'�I ', � � � ��.tl . � �j� � . '� . j � l l I� G��� . � 1�. �!� :.-X <br />Prolect Address (if known) � <br />Attach four (4) copies of plans for proposed work - Draw to scalr, and note the lollowing as applicable: <br />• Property Lines <br />• Outline end dimensions ot all ezisting and <br />propOsad ShuCtures On the lot <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />• Centerline of street <br />• Indiwte Norih <br />� Show any propoeed grading changes <br />• Show measurements <br />i. All calls for inspection shall be m�de 24 hrs in advance • phone 259•881 5. <br />2. All work shall be peAormed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />,r�, /� T— Gcip�,/� rG.-ed jJ.� -�S <br />�' / <br />�-��/%!�� r3 -.3 -8s� <br />Appr� lor onstruction Date <br />FINAL INSPECTION Date <br />Approved es Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259�BC75 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett trom any and all claims for dama�es, costs, <br />exp^nses, or causes of aclion that may arise because of installation <br />and maintenance of the improvement or other right•ol-way use herelo <br />app!ied for antl lurther agrees to remove same upon notice irom the <br />City and to replace public property damaged thereby. <br />� ,� � � <br />�� �1 � C� 4����,, � f ti� i���I �h l��I <br />Signature of Applicant � � Date <br />WORK AUTHORI2ED BY THIS PERMIf MUST BE STARTED WITHIN <br />180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. TNIS PERMIT MP.Y BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 50 DAYS DURATION. <br />