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• <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />T RE�t.9tE 8S-3GZ <br />Public Works Permit a p / — 103 <br />Bldg. Dept a <br />Public Works ree $ <br />Total Fee <br />Less Ap 1, Fee Paid i <br />Balance Due S ti� 6-4pm-6E <br />w c7s8-&- <br />S �� ant, CY(r(S q g,-�01 h. a T-3a� 1 <br />ailing Address City Zip Phone <br />i <br />aili ig fvi.• ess City Zip Phone <br />Describe Proposed Work t ve (,ja.\4 4 aCceIE;S- <br />W <br />Project Address (if known) �� ey a 0 <br />Attach four (4) copies of plans for prr posed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed struc!ures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS y7 Q_ &"300 <br />O <br />1. All calls for inspecticn shall be made 24 hrs. in advance - phone 2504MU. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />31 ji G'r fO�tlS.—i�'vlTis /� f Fit el;y ST.?ivtp9/!> '�31g8 <br />O <br />/�E-c' :cririr�c <br />-s <br />Approved for Construction ! Date <br />S-G-F <br />INSPECTION —�� Dale <br />Approved as Constructed <br />everett PUBLIC WORKS `)EPIRTMENT <br />Everett, WA 98201 <br />Phone: 259-8815 <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of inslaltation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant 1 1 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 DILIGENTLY PURSUED TO COMPLETION, THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />