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I PuClic Works Permit r V� // �� ' <br /> Date�� � 0 <br /> eiao oeo��• <br /> Appiication For <br /> PUBLIC WORKS PERMIT PuOTolalFeaFea S �o , mo <br /> Less APG�Fee PBitl S <br /> ealence Oue S �O.O V <br /> Print or Type Only <br /> �� � ����n-c ✓ / Ylo Dals�s <br /> Owner Mailing Address City Zip Phone <br /> N��.� r-� � ,�.�.-75-3z L� w �,- ��, 1� �, r��/ �� �-3 -���.�-9 <br /> Applicant Mailing Address City Zip Phone <br /> Descrihe Proposed Work � u��/ h 't W �' • "�`y C '� C�✓—� �y a c �P _ <br /> � <br /> ' �.� � �3 -� �s- �3 <br /> W <br /> Project Address�if known) � y�� � dL.,/��`�-s � <br /> Attech four(4)copies of plans for proposed work• Draw to scale and note the following as applicable: � <br /> • Property Lines • Centerline o(street � <br /> • Outline and dimensions of all existing and • Indicate North <br /> proposed struclures on the Iot � Snow any proposed grading chenges <br /> • Ezisting and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance• phone 259•8815. � <br /> 2. All work sha�l be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards and Specifications <br /> 3. Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> O <br /> � <br /> � <br /> O <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less the City of Everett irom any and all claims for damages, costs, <br /> Q expenses, or causes of action that may arise because of installation <br /> 8�,� - r3 and maintenance of the improvement or other right-of•way use hereto <br /> applied lor and lurther agrees to remove same upon notice from the <br /> pproved tor Constructi G��� Date City and to rePlace Public proPerty damayed thereby. <br /> ��1G- ��' j� � <br /> 'FINAL INSPECTION Date <br /> Approved as Construcled Signat e of Applicant °�e <br /> everett PUBLIC WORKS DEPARTMENT H'ORK AUTHORI2ED BY THIS ERMIT MUST BE STARTED WITHIN <br /> 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everelt, WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON TH�:i <br /> Phone: 259•8815 PROJECT OVER 90 DAYS DURATION. <br />