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Date /Df�/�f' <br />/ Y <br />Applica�ion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />Describe Proposed Work <br />Project Adtlress (if known) <br />� <br />CtlY 2ip <br />PuOLc AYp�As Ve�mil •_p� <br />DiOB OePt • a _�//�j� <br />«..� <br />PubLc Worhs Fea <br />Toldl Fnc S <br />Less Apo�� Fce Pn�d $ <br />Balancc0ue $ <br />Attach four (4) copies ol plans Im proposed work • Draw to scale and note the following as apphcabie: <br />• Properly Lines • Cenlerline ol sireel <br />• Outline and dimensions of all eaisting and • Indicale North <br />proposed slructures on Ihe lot • Show any proposed �rading changes <br />• Existing and pwposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor inspeclion shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be peAormed in accordance with this permit and current Cily ol Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. beto�e you dig. TOLL FREE NUMBER 1-800-424-5555. <br />�U��e( Gvo�/� �z»..�:T` /l�c� %�e��.Zu-� /i / B 8 <br />��� <br />ApproveA lor Construction Date <br />FINALINSPECTION Date <br />Approved as Conslrucled <br />rve�mlt PUBLIC WORKS DEPARTMENT <br />� 3200CedarSireet <br />Everclt. WA 98201 <br />Phone.259�8810 <br />ACKNOWLEDGLIdENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />�� <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned owneUapPhtant hereby agrees to hold and save harm- <br />less Ihe Gty of Everetl Irom any and all claims lor damages. costs. <br />expenses. or causes of action that may arise because ot inslallahon <br />and mamtenance ol Ihe improvement or othe� r�9ht�oFway use hmelo <br />applied lor and lurther ag�ees lo rCmove same �pon nohr.e Irom Ihe <br />Cily and �o replate pub6C prOper�y tlamac�etl thereby <br />Signature ol Applicant pi��, — <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PLRh11T IS ISSUED AND THEREAFTEF IS TO <br />BE DILIGENTLY PURSUF.D TO CQ;if'LC?iUN. iHIS PERM1tIT tdAY �E <br />CANCELL[D BV TH[ CI7V U; UN t�NY STOPP�G[ OF INORK O!1 fH15 <br />PROJECT OV[R JO DAYS DURATION <br />