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� y <br />C�� <br />�H� <br />H�H <br />'V �'9 <br />yN�� O <br />GMd <br />i:�� <br />r�Jy� <br />O�M <br />���A <br />�� <br />� <br />� <br />•'- , <br />C�ate�✓� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print orType Only <br />Mailing <br />Applicant <br />Atldress City <br />Describe Proposed Work [ lA/1���t d� � S� K <br />Prolecl Atldress pl known) <br />�� <br />.� <br />� 'PUELc1YorASPeimn• `�,323_ <br />B�eO Deo�� • <br />PuLI¢ Worna �sc <br />TO'TI iP! S <br />LesSFppl (CePaq $ <br />9aience Doe S <br />Atlach lour (4) copies ol plans for proposetl work - Draw to scale and note Ihe lollowing as applicable: <br />• Property �ines • Centedine ol sireet <br />• Outline and dimensions oi all ezisting Tnd • Indicate North <br />pfopOSEd Sirudur@5 On �he lo� • Show any proposed �radinr� chanc�� ; <br />• Existing and proposed utilities • Show measurements <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspedion shall be made 24 hrs. in advance - phone 259-8810. <br />2. kll work shall be pedormed in accordance with ihis permit and current City of Everett Design and Construction <br />Slandards and Specifications. <br />3. Call Location Underground Service 4B hrs. before you dig. TOLL FREE NUMBER 1-800•424•5555. <br />J"i��-�.e' Cuv�l� Pe�.r,,��/1/a-t�'e� <br />Approved for Consir�clion <br />FINAL INSPECTION <br />Approved as Constructed <br />evcrctl PUBLIC WORKS DEPARTMENT <br />� '+200 Cedar Sireet <br />Everett. WA 98201 <br />Phonc�.259-8810 <br />�-4 ��B <br />�� <br />ACKNOWLEDGEM1+ENT OF CONDITIONS <br />W <br />H <br />_ / <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned ow•ner/apphcaM hereby agrees �o hold and save harm� <br />less the Gry ol Everett Irom any and all claims tor damages, costs, <br />exoenses. or causes ol aclion that may arise because of installalion <br />and maintenance ol the improeement or other nghl-ol�way use hereto <br />applied br and lurther aarees lo remove same upon notice Irom Ihe <br />Date City and lo replace puUlic property damaged tl•ereby. <br />Date <br />Signature of Applicanl Date <br />WORK AUTIIORIZLD BY THIS PERMIT MUST BE STARTED WI7HIN <br />180 DAYS OF DAT[ P[RMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTL� PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THG CITV UPON ANV STOPPAGE OF WORK JN THIS <br />PFOJECT OVER 90 DAYS DUFATION. <br />