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v <br />Date%` � � yL —�, <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />L �- G.�..�_ C.�-�-�.�� � <br />Owner Mailing Address <br />.� <br />Applicant <br />Describe Proposed Work <br />Project Address (if known) <br />Mailing Address <br />' C; � <br />>>. , ��_ <br />�� , <br />Ciry <br />i <br />r�� <br />� <br />PuObc Worka Permn • <br />BiOP Deol.l�' ^ :�" %' rl <br />PunLCWorMSFee S <br />iolal fee <br />Less RnP�� �ee Pard S <br />eaiance Due S <br />• L�.J�I ���%! � ' -' ' -Y�S- <br />2iP Phone <br />Zip Phone <br />Attach four (4) copies of plans for proposed work � Draw to scale and note the following as applicable: <br />• Property Lines • Centerline ol st�eet <br />• Outline and dimensions of all existing and • Indicate Norih <br />proDosed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />7. All cails lor inspection shatl be made 24 hr� �n advance - phone 259•8810. <br />2. All work shell be performed in accordance with ihis permit and current City of Everett Design and Construction <br />Standards end Specifications. { <br />3. Call Location Underg�ound Service 48 hrs. before you dig. TOLL FREE NUMBER 7•800-424•5555. <br />iV , r'•' `'l 1 �. \�uiL�<.'_ �LN� � F���.�,. <br />�cc�.r-�., f ►j ` kx.�. <br />i� -�;-5u <br />A�provecl for Construction <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLICWORKSDEPARTMENT <br />� 3200CedarStieet <br />Everett. WA 98201 <br />Phone:259�BB10 <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />ACKNOWLEDGLMENT OF CONDITIONS <br />The undersigned owneUapplicant hereby ag�ees to hold and save harm� <br />less the City of Everett Irom any and all claims for damages. cos�s. <br />expenses. or causes ol action Ihat may arise because ol installa�ion <br />and maintenance ol �he improvement or other riqht-obway use hereto <br />applied lor and further agrees to remove same upon notice irom ihe <br />City a,id to replace public properry damaged Ihereby. <br />Signatw�e of Applicant Date <br />WORK AU?HORIZED BY THIS PEFMIT MUST BE STARTED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUED AND THC-f;EAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. TIiIS PERMIT MAY BE <br />CANC[LLED BY THE GTV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVL=R 90 DAYS DUFATION. <br />