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Date��/ <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />s1hc 3z <br />Mailing Address <br />Applicant <br />Describe Proposed Work <br />x^�r,.f7_ICllnc, I n r <br />I'M <br />Ppbbc Works P.1o,d • Bldg Dept. ❑ept. s <br />Ppbix Works Fee i <br />Total Fee <br />U,R Apo; Fe: Paid <br />Balance ova <br />.r �6Tj�o <br />�kZn/ 25-�--c <br />Phone <br />Zip rnone <br />Project Address (if known) =X777ITra`M- ✓e_ I r '(4d C I "e'e <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />j2.2rt'T <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />All calls for inspection shall be made 24 hrs. in advance - phone 259.8815, <br />All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />Approved as Constructed <br />i <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />W <br />I-- <br />Im <br />O <br />z <br />O <br />O <br />a <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 />Date City a . replace public property damaged thereby. <br />T Dale <br />Si nature 0111APPficant <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 />r <br />