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Date <br />� <br />Appllcetion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Addreas <br />Pupl¢ Worlu Pom1i • <br />Blpp. Dpt. r _ <br />Pueik work. Fe� <br />TW�IFN = <br />l�t� ApPL F�� P�M { <br />B�I�na Du� i <br />City Zip Phone <br />.: - - ' � . •• <br />• • �. � . � <br />Prolect Addreas (ff known) <br />Attech four (4) copien of plens for Droposed work - Draw to acale and note the following as applicable: <br />• Property Llnea • Centerline ol street <br />• Outllne end dimenaions of all existing end • Indicate North <br />proponed atructurea on the lot • Show any proposed gradinp changes <br />• Ezistinp and proposed utllitles • Show measurements <br />PEHMIT CONDITIONS <br />1. All calls for inspectian shall be mede 24 hra in advance • phone 259•8815. <br />2, All work ahell be peAormed in eccordance with this permit ar�d current City of Everett Design and Construction <br />Stendards and Specilicationa <br />3. Call Locatlon Underqrountl Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />/'����� <br />�9 Pw b�-� , � <br />,�e�"' � <br />��.,,�� <br />S,,o,Fy��/�,,►�- <br />/ � ACKNOWLEDGEMENT OF CONDITIONS <br />hpproved lor Construclion Date <br />FINAL INSPECTION Dete <br />Approved as Constructed <br />everett PUBIIC WORKS DEPARTMENT <br />� 3200 Ceder Streal <br />Everett, WA 98201 <br />Phone: 259-8815 <br />W <br />H <br />� <br />� <br />N <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the City of Everett Irom any and all cleims lor damages, costs, <br />expenses, oi ceuses ol action that may arise because of instellation <br />and mainten.ince of tha improve�nent or other righl-o4way use hereto <br />applied lor and lurther agrees to removr same upon notice Irom lhe <br />City end to raplace public property damaged thereby. <br />Signeture of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 D�IYS OF DATE PERMIT IS ISSUED AND THEFEAFTER IS TO <br />BE DILI�ENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE GITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 50 DAYS DURATION. <br />� <br />� <br />� <br />