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I <br />41 <br />Dates*4s <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Pubbc Works Permit a 13 ' Z o <br />Bldg. Dept a <br />Public Works Fee aS <br />Total Fee -�0 <br />Less Appl. Fee Paid S <br />Balance Due >< <br />ao <br />3ass <br />SGit� <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work <br />- _ W <br />Project Address (if known) �l"ELi � <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property 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 259.881 5. <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 hr1s., before you dig. TOLL FREE NUMB . <br />ER 1 -800(-424.5555. <br />ok;P v� <br />/• �N,1 7,Rt1wa11� C.��cP 1� L3icr- /'�bI <br />rokf <br />ILons\�K tt lo. 71(L at\ be %CC riC CC.Y to 41e, a"fill e O <br />Div `Lt SQAss4` .A1T ION YS PN.L. "0 3 SNe�Pc <br />O <br />a <br />.r-.2 s- <br />Ipproved for Construction Date <br />INAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />Everett, WA 98201 <br />L 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, cost•L <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 IN) <br />City and o replace public property damaged thereby. <br />u - t�� _;� <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 WORD: ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />al <br />.) 1 <br />