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oate�8 7 (` <br />� � <br />Applicatlon For <br />PUBLIC WORKS P�RMIT <br />Print or Type Only <br />Applitent <br />DeseNbe Proposed Work <br />PrO�ect Addrou Uf known) <br />Meiling Address <br />B ;� <br />� <br />PuElic Works Permlt e <br />B�Op. Depl • y ��� <br />Pu01k Works Fee <br />Tolal Fee s <br />Leat Appl Fee P�iE s <br />Bslance Due s <br />Att�ch four (4) copiee of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property Linea .• Centerline of street <br />• Outline and dirensiona of all axisting end • Indicate NoKh <br />propo�sd atruct�rea on the lot • Show any proDoaed gredinp chnnges <br />• ERi�tl�p end propased uti�ities • Show measurements <br />�"2 <br />Phone <br />Phone <br />PERMIT CONDITIONS <br />1. A!I GII� for Inapaction ahell be made 24 hra in advance • phone 259-8815. <br />2. AN work Mtll Oe peAormed In accordance wdh thin permit end wrrent City of Everett Desipn end Construction <br />St�nAud� and SpecMlcetlone. <br />�. GI! Loc�tlon Underpround Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800�424•SS55. <br />`f—/ S <br />/S TNi � TNE EXPA�S iDN <br />oF TAyco�e S Tor �vT � <br />(AKA SEPA 86- 23� <br />OR TuST A REPU/GD Of <br />Sa,y� DA�PTS Q� $�Fo�CE�I ? <br />7�.x�N RGTAiNnli^�6' wA[tS� <br />SF on��- i RE�� �� - nio ftieuc <br />WG►QK1 ��?m�T n�EQUi�ED <br />K,� <br />Apprcved fm ComtrucNon Date <br />flNAI INSPEC710N Dete <br />Approvnd u Constructed <br />. �� QUQLIC WORKS DEPARTMENT <br />� 3200 Ceder Sireet <br />Everett, WA 98201 <br />Phone: 2ti9-Mfi p$'OCi <br />ACKNOWLEDGFMENT OF CONDITIONS <br />The undersigned owner/applicant hareby egreee to hold and seve harm- <br />less ihe City oi Everett from eny end all claims for damepe0. costs, <br />expenses, or ceueas of actlon thet mey erlee beceuee of inetallation <br />and melntenance of the fmprovemenl or other righFof-wny uea hereto <br />applied tor and further egreee to �emove eame upon notice from the <br />City and to roplace public property demaged thereby. <br />Signelure ot Applicent Date <br />WORK AUTHORIZED BY THIS PEFMIT MUST BE STARTED WITHIN <br />100 DAYS OF DATE PEfiMIT IS ISSUED P.ND THEREAFTER IS TO <br />BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUflATION. <br />