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Date�� <br />/ � <br />App�icalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Oniy <br />LL <br />/y� SO <br />Mailing <br />zm <br />Fultlic lYaAs Pcimi� c• BC� � ✓ <br />aiea o�o� . Q�� � L _- <br />P.:'.., WOikS �ee S <br />Totnl Fee <br />les.ApP� FecPai� S <br />�alance Dun S �0�- <br />.. � <br />��„�� ��TUGT.�nJ q� o� �rF�f,�,�rr-.��r, g ��� � 7�a <br />Applicant Mailing Address � City Lp Phone <br />Describe Proposed Work /I�fu� �QF—� ��3'S � ���'�1��� � <br />Proiact Address lif known) <br />Attach four (4) cop��::. ol pians for proDosed work - Draw to scale and note Ihe lollowing as applicable: <br />• Pr� oerty Lines <br />• Out��ne and dimensions of all exisling and <br />proposed siructures on ihe lol <br />• Existing anC proposed utilities <br />FINAL IASPI <br />Approved as <br />everett <br />e <br />• Centerline of street <br />• Indicate �'�rih <br />• Show any proposed grading changes <br />� Show mea5ure.nenis <br />PERMIT CONDITIONS <br />1. All ca.is !or inspection shal� be made 24 hrs. in advance • phone 259-881 O. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standerds and Specifications. <br />3. Call Locetion Underground Service 48 hrs. betore you dig. TOLL FREE NUMBER 1-800�424•5555. <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 9A201 <br />Phone:259�8310 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersi9ned owner/applicant hereby agrees to hold aod save harm� <br />less the C�ly oi Everelt Irom any and all claims lor damages, costs. <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other righbol-way use hereto <br />applied for and further agrees to remove same upon not�ce irom the <br />Ciry and to replace pubGc prope�aged thereby. <br />� � / <br />L sj�'�'�d /�B-Sr <br />61 naiure of Applicant � Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />DE DILIGENTLY PURSUED TO COMPLETION. THIS PERA7IT MAY BE <br />CANCELLED BY THE C�TY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS OURATION. <br />