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Date � � �'�' <br />Applicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applitent <br />Describe Proposetl Work <br />Pr ecl Address (if known) <br />Address <br />r- <br />Zip <br />Attach tour (4) copies ol plans for proposed work • Draw to scale and note Ihe following as applicable: <br />• Property Lines <br />• Outiine and dimensions of all existing and <br />proposetl structures on the tot <br />• Existing und p�oposed utilities <br />Puol¢ Works Permit • <br />niae Deo�. + ��— <br />!� <br />Pu�llc Worke Fee <br />Tolal Fee s <br />Less ADp�� Fee PxiC S _ <br />esia��e o�a <br />• Centerline of stree! <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor (nspection shall be made 24 hrs. in advance- phone 259•881 O. <br />2. All work shali be per(ormed in eccordance with this permit and current City of Everett Design and Construction <br />Stendards and Specifications. <br />3. Cell Locetion Underground Sarvice 48 hra before you dig. TOLL FREE NUMBER 1-800-424-5555. <br />��u��u a.+�o- f��7` /�/O.t R�t�.�.,,,a0 <br />'`_'�ofl� .��.G�.-�o ��� �4�� <br />�� �a���� <br />� <br />.���� s�� <br />%d,s d��r�-r,Po�✓ o,e a�: r,�✓ . , �' <br />Approved br Construction Date <br />fINAL INSPECTION Date <br />Approvad as Constructed <br />everett PUBLIC WORKS OEPARTMENT <br />� 3200 Cedar Street <br />Evere��, WA 98201 <br />Phone: 259-BB70 <br />�� /��� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />F- <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hoid and save harm• <br />less Ihe City ol Everett Irom any and all claims for damages. costs, <br />ezpenses, or causes ol action that may arise because ol installalion <br />and maintenance of the improvement or olhe� right-ol•way use hereto <br />applied lor and further agrees lo remove same upon �otice from the <br />City and to replace public property damaged thereby. <br />Signature ol Applicant Date <br />WORK AUTHORI2ED 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 DAVS DURATION. <br />