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Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public works Permit • / p <br />Bldg. Dept. e l �uf 7 <br />Public works Fee $ <br />Total Fee <br />Leas Aplot Fer Pad $ <br />Balance Due $ <br />Owner IMailing Address City Zip Phone <br />G P P e C2,aT��r,r �. A &--Y C-J6603 �'jihllol)od /R94 779-0,15 <br />Applicant Mailing Address rity Zip Phone <br />r / <br />Describe Proposed Work r �% FuJ 7- i <br />r <br />--W <br />Proiect Address (if known) r� I{JGY <br />Attach four (4) copies of plans for proposed work- Draw to scale and note the following as applicable: <br />• Properly Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS O <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8815. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />O <br />a <br />Approved for Construction Dale <br />FINAL INSPECTION <br />Approved as Constructed <br />t•vera•p PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses. or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant 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 CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />