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Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />; � q�; <br />Pu01ic Wo�ks Permit a <br />�;_:-,,'��� <br />Bltlg. Depl. + <br />PUGIic Works Fee s <br />Total Fee <br />Less APO� Fae Paitl S <br />y% <br />Balance Duo S <br />� 1 i �i .t ' , � f ���:� . . `; �i � � � .� � `,'j . i . , -�,- . - � - � <br />� Owner MailingAddress Ciry Zip� Phone <br />Describe Proposed Work <br />Mailing Address City <br />�G? <br />�.��i b i,-'; �? C»: C <br />; � a_,r . . <br />�� <br />C�..t � � \ �-{� �'> i �-- <br />� � <br />��r�t-'�. ..-r-- �... � .. �� ..�;- - <br />"_ �-.. �:., �. . . 1 _.. , -.� �<- ';' <br />Project Address (if known) . <br />Attach four (4) copies ot plans for proposed 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 structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measuremenis <br />PERMIT CONDITIONS <br />1, All calls for inspection shall be made 24 hrs in advance • phone 259•881 5. <br />2. All work shall be performed 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. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />c _.. _ . J �.� � <br />-. , c 1 � C - <br />�� /.r�'� _, -��� Cn ; rj�°:�% __ �-- r-. . _, <br />y1;';x ' C �,,,��, k_t, ., 1 �� :�' � C"� b� <br />_ �C� c-p �uk�?c;v�J�i ���, s'T2��iS F�' < �� ,= <br />_ �, ,-, - <br />� - , �:_ � ,�.�_. <br />� _ � i i° " i � =� <br />1! , -, �' , i 1 `v f _ <br />Approved for Constructi Date <br />` <br />., 8—/� — �S <br />F L INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DE?ARTMENT <br />� 3200 Cedar Slreet <br />Everelt, WA 98201 <br />Phone:259�8815 <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEMENT OF COND�T�ONS <br />The undersigned owner/applicant herr� agrees to hold and save harrn- <br />less ihe City of Everett irom any ar ell claims for damages, costs, <br />expenses, or causes ot action that i.. y arise because o1 instaltation <br />and maintenance of the improvement or other right•of•way use hereto <br />applied lor and further agrees to remove same upon notice irom the <br />City and to replace public property damaged thereby. <br />, � <br />,;, _-,�fi. <br />, , , , ,� ,; >..s <br />Signature of Applicar.t� � 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 WORh ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />e <br />� <br />J <br />