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Date�t �� D� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Punlic worxs Pm � � <br />oieo 000�� • <br />Pubbc Wo�ks Feo S <br />Totoi Fee <br />Less Appl Poe Pnid $ <br />Balance Oue S <br />Mailing Address <br />Describe Proposed Work ` �, ` ��L._-_• � <br />Gty Zip <br />Proiect Address �il known� �L�-� /o�Y LL� 4..� /'Cla <br />Attach four (4) copies of plans lor proposed work - Draw to scale and note the following as applicable: <br />• P�operry Lines <br />• Outline and dimensions of all ezisting and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />Approvedfor <br />• Centerline ol street <br />• Indicate Nor�h <br />• Show any proposed grading changes <br />• Show measurements <br />PERMITCONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259•8810. <br />2. All work shall be performed in accordance with this permit and currenl Cily ol E��erett Design and Construction <br />Stanoerds and Specilications. <br />3. Call Location Unden�round Service 4B hrs. before you dig. TOLI FREE NUMBER 1-800-424-5555. <br />YIC�i" �'��v� ��I] <br />Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />�verett PUBLICWORKSDEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone: 259�8870 <br />� � � BG3 <br />; �<�;. � �� <br />ne <br />�CKNOINLEDGEMENT Or CONDITIONS <br />� <br />� <br />H <br />N <br />� <br />a <br />The undersignatl owner/applicant hereby agrees to hold antl save harm� <br />Iess ihe City ol Everetl Irom any and all claims lor Aamages, costs. <br />ezpenses. o� causes ol action Ihat may arise because ol installa�ion <br />2nd maintenance ol Ihe improvement or olher ri�hPof�way use hereto <br />app�ieA lor and lurther agrees to remove same upon noUce Irom the <br />City and to ren��ce public pronerty dama9ed thereby. <br />Signature ol Apphcant Date <br />WORK AUTIIORIZ[D BY TIiIS PERMIT MUST BE STARTED WIiHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIG[NTLV PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />