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Date�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mamng <br />Pu01¢ Worka Permit • � �✓ l G <br />B�ap DeO�-• <br />��c Worha fee <br />TofalFee t <br />Lea� AODI Fee PaiO S <br />aQ po <br />Bal�nce Dee S <br />z�u <br />Zip phone <br />Describe Proposed Work �,Ll?,j`Q �c.� �'���[�t,�.l �^��� '�(�, n�P y <br />r, � <br />Project Address (il known) <br />Aftach four (4) copies of plans for proposed work • Drew to scale and note the following ae. applicable: <br />• Property Lines <br />• Outline and dimensions of all ezisting and <br />proposed structures on the lot <br />• Existing and pioposed utilities <br />PERMIT CONDITIONS <br />• Centerline ol s�reet <br />• Indicate North <br />• Show any pioposetl grading changes <br />� Show mea5uremenis <br />1. All calls lor inspection shail be made 24 hrs. in aAvance - phone 259•881 5. <br />2. All work Shall be performed in accordance with Ihis permit and current Ciry oi Everett Design and Consiruction <br />Standerds and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />�✓.5,—/�GC C'i9T«/ t�F�JSi•✓S /'cS /ia-�--;7 �.�J <br />�i',�':'c���-n 1,�:..��.L:� �:,�v:�` <br />P� <br />W a��� G' <br />�' � C. <br />��'� <br />'��`'��� 9�� .�6 <br />Approved lor Co rGction / [�ate <br />� / / - 7 �(� —I � <br />FINP.L INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />I Phone:259-8815 <br />ACKNOWLEOGEMENT OF CONDIT�ONS <br />W <br />F- <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant I�e�eby agrees to hold and save harm• <br />less the City ol Everett irom any and all claims for damages. costs, <br />expenses, or causes oY action that may arise because of installation <br />and maintenance ol the improvement or other righFobway use hereto <br />zp�lied tor and turther agrees to remove same upon notice from the <br />City and to replace pub�ic property damaged Ihereby. <br />:��� ���% �_� h 5�5'�j <br />Signature of Applicant Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STAHTED WIiHIN <br />180 DAV$ Uf DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLV PURSUED TO CnMPLETION. THIS PERMIT f�IAY BE <br />CANCELLED BY 7HE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 9G DAYS D�!RATION. <br />