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Date��y <br />Appllcation For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Pv�nc \Porks Per It • �� <br />3�7 <br />eiea oaai.. �-i � <br />Public Works Fee S <br />.o,,, Faa <br />lees Aoo� fe � Pa�C S <br />Belnnce0ue S 2����� <br />Describe Proposed Work <br />Prolect Address (if known) " <br />A�twr.h four 141 cooies ot plans for proposed work • Draw to scale and note the lollowing as applicable: <br />• Properry Lines <br />• Outline and dimensions ot all existing and <br />proposed strucWres on the lot � <br />� Existing and proposed u�ilities <br />PERMIT CONDITIONS <br />• CenteNine of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />1. All calis for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everetl Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMEiER 1-800•424•5555. <br />��� ��s,Gf�.�_ /z� l s� <br />Approved tor Cons�ruction Date <br />�� . �i' �� ? .'/' cf`J <br />FItJAL INSPECTION Date <br />ApprOved as COnslructed <br />rvcrMt PU�LIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98:01 <br />Phone:259�8815 <br />ACKNOWLLDGEMENT OF CONDITIONS <br />� <br />�J <br />The undersigned owner/apphcaM hereby agrees to hold and save harm- <br />less ihe Ciry ol Everett irom any and aP ciaims for damages, cosls, <br />expenses, or causes of action that may arise because ol installation <br />and maintenance o! the improvemen� or other righDo6way use hereto <br />applied for and lurther agrees lo iemove same upon notice from ihe <br />City and to replace public properry dama9ed �hereby. <br />J , ( % `i'�. <br />,�' ' ��� <br />, � �� �. <br />Sign�'ure ot Appf � Date <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTE� WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CPNCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PFOJECT OVER 90 DAVS DURATION. <br />� � <br />H � <br />� � <br />r <br />MC <br />O '. <br />�� <br />� <br />g: <br />�: <br />r+ � <br />�3 C <br />K <br />O� <br />� � <br />�r <br />�;. <br />�3 : <br />L <br />