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� Date�4�T/ �� <br />Appllcetion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />S <br />Address <br />Address <br />Describe Proposed Work <br />Pro�ect Addrase (N known) <br />pueuc Wort� Permu �`—/�S <br />Blap. DepL • <br />VuObc Wark� Fae <br />TolalFee =— <br />Lear Appt Fee Pe�U S <br />BelanceDue S �O�QU <br />G�p <br />� ,� <br />Zip <br />rnon� <br />ba �-a� <br />Attech tour (4) copiea of plans for proposed work • Draw to acele and note the following as applicabie: <br />� Proparty Llnea • Cen!erlira of street <br />• Ouiline end dlmensions of ell existinp and • Indirale North <br />proposed siructurea on the lot • Show any Rr�posed grading changes <br />• Ezietinp and proposed utilities • Show measurements <br />,l'0'7� - �f40(o <br />Go,u'M�X-- t� <br />PERMIT CONDITIONS <br />7. Atl cells for Inspeclion shall be mede 24 hrs in advance - phone 259•881 5. <br />2. All work ahall be pertormed in accordance with this permit and current City of Everett Design and Construction <br />Standerda and Specifications <br />3. Cell Locatian Underground Servlce 48 hra before you d�g. TOLL FREE NUMBER 1-$OO•424-$S5$. <br />Tr PL�✓E At GEdST TNE {/.c'ST .20 � O� d.i/diWA�, <br />STA�Ti.�C* AT Ti�E STREET, <br />L(iC .SClGCrEST �pl/ ma.rE- T�� D.e.ar-�✓<�� A/'vl/NiMG�M <br />of �� � a�iDE . <br />.�,! ��.Y <br />Approved for Co- huction Date <br />���a��� G if'� <br />�FINAL INSPEC ON Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98207 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett irom any and all claims for dameges, costs, <br />expenses, or causes of action that may arise beceuse of installation <br />and maintenence of the improvement or other right-of-way use hereto <br />applied for and turther agrees to remove same upon notice (rom the <br />City and to replace public property damaged thereby. <br />� � ` q�l�� <br />Aow. o <br />Signature of ApPlicant r� ��e <br />WORK AUThIORIZED 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 P[RMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />