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Date�l:�-�I <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Appliwnt <br />Describe Proposed Work <br />Prolect Address lif known) <br />Malling Address <br />c�ii <br />Attach four (4) copies ot plans for proposed work - Draw to scale and note the'ollowing as applicable: <br />� Property Lines <br />• Outline and dimensions of all existing antl <br />proposed structures on the Iol <br />• Existing and proposed utilities <br />�3-�9� ,�"!•' <br />PubOc WorAe Pacr�.��y,�, LC—,�.--�—"� <br />oinv oro� , ti-1—t�� �--v._.(1— <br />Public Wor45 Fee <br />1o1a1 Fee S — <br />Less ApO� Fee PaN S��� ('� � <br />6alancr0uc S.£ �" _ <br />• Centerline ot street <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measuremenis <br />PERMIT CONDITIONS <br />1. Ait calls for inspection shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be peAormed in accordance wl:h ihis permit and current City of EvereU Design and Construction <br />Standerds and Specilications. <br />3. Call Location Underground Service 48 hrs. belore you tlig. TOLL FREE NUMBER 1-800�424-5555. <br />� /l :' f,`LL /.r T�,- h'�' <br />iL�r� ���,�� .-�,��� �. <br />/� �CF-�> /.� 7i%�' <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Eveie�t. WA 98201 <br />Phone:259�8810 <br />ACKNOWLEDGEIdEM�OF' �NDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />0 <br />a <br />The undersigned owner/applican; hereby agrees to hold and save harm� <br />less the Cil,� of Everelt Irom any and all claims for damages, costs, <br />expenses, or causes ot action that may arise because of installation <br />and maintenance of �he improvement or other righ�-o4way use hereto <br />applied for and further a�rees to remove same upon notice Irom Ihe <br />City qd to replace pubfic p� perty ��aged thereby���� <br />/ <br />WORK AUTHOHI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT �S ISSUED AND THEREAFTER �S TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED 8Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUFATION. <br />