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1 <br />Ir' <br />r <br />L <br />ogte s - a - $y <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Applicant <br />Oeacribe ProposeA Work <br />Pro�act Address (if known) <br />�� <br />Address <br />Meiling Address <br />City <br />PuClic Work� Permit ��� I�� <br />BIEO Deot • <br />PueM1CWorkeFee s y�. � � <br />Tol�l Fse <br />Leu Aopl Fee PaiC i -1�� <br />g�bnce Due S C "' � � <br />Attech lour (4) copies of plans for proposed work - Draw to scale antl note the following as �pplicable: <br />• Property Lines • Centerline ol street <br />• Outline and dimensions of ell existing and • Indicate North <br />proposed atructures onthelot • Show any proposed grading changes <br />• Ezisting and proposed utiiities • Show measurements <br />PERMIT CONDITIONS <br />Phone <br />t. All calla tor inspaction shall be matle 24 hrs. in advance - phone 259•881 5. <br />2. All work ahxll be peAormed in accordance with this permit and current City of Everett Design and Construction <br />StanAards and Specifications. <br />3. Ce�l Lrxetion Untlerground Service 4B hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />rs� <br />4FpprovU3 for C�tion oate <br />�� � i>1e <br />FINAL I SPECTION Date <br />Approved as Constructetl <br />everett PUBL�C WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259•8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />"�1 <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant here�y agrees to hold and save harm- <br />Iess the City of Everett from any and all claims lor damages, cosls. <br />expenses, or causes ot action that may arise because ol installetion <br />and maintenance of the improvement or other right-of�way use hereto <br />applied for and furlher agrees to remove same upon notice Irom the <br />City and to replace public property demeged lhereby. <br />�L�-�-�, ��� l c � ;� � �,�y <br />Signature of Applicant Date <br />WORK AUTHOFIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF CATE PERMIT IS ISSUED AND THEREAFTEfi IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE GITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 50 DAYS DURATION. <br />..� <br />G�i <br />