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Date��'✓ <br />K— 31-zg -S'- <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />/ <br />9a( I�.�Z <br />Publm, Wa�k. Permlt e <br />eiaa oani., 0 L�/ I,SQ <br />PuElic Worka Fce <br />Totel Fee S <br />I.esc Rppl. Fee PaIE S <br />Balance Due S � � <br />rnone <br />54 vN �L <br />Applicant Mailing Address City 2ip Phone <br />Dr.scribe Proposed Work <br />Pro�ect Address (If known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lioes • Centerline of street <br />• Ou�line and dimensions ol all existing and • Indicate Norih <br />proposed s�ruC�ureS on the lot • Show any proposed grading changes <br />• Existing and proposrd ulilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor irspection shall be mede 24 hrs. in advance - phone 259•8810. <br />2. All work shalt be pertormed in accordence with this permit and current City of Everett Design and Construction <br />Standards and Speci(ications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424•5555. <br />�}. "�2�vE4.iA`� S++A�.L No i BC t�lo��t �-+-1�,�.1 <br />3" �-i � e, �+crz i'i-1 A N ��►�rer� c�r= c�� s��� N G <br />orL <br />�AvEf7 S'ilzC�='� A; TtIC F�� NT l�l FI�'1ZC ��' <br />L �OaS�T i�tC ��o1=�7Zi� C_iNl= . <br />Approved for <br />FINAL IN5PECTION <br />Approvetl as Constructed <br />everet[ PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259•B810 <br />uare <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEA!cNT OF CONDITIONS <br />The undersigned owner/app!�cant hereby agrees to hold and save harm- <br />less ihe City of Everett irom any and all claims for damages. costs. <br />expenses, or cause� ol action that may arise because of ,�istallation <br />and m�inlenancP ol the improvement or other righl�ol�way use hereto <br />applied lor and lurther agrees to remove same upon notice Irom the <br />Cily and to replace publ���op y damaged thereby. <br />Sig re ol ApP�� ant 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 GITY UPON ANY STOPPAGE OF WORK ON THIS <br />PFOJEC7" OVER 9U DAYS DURATION. <br />