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i <br /> I <br /> /� (+/ .-, --� <br /> DateJ_S_YSL� �/ Pubhc Warka Pe�mlt O+ ���� <br /> AppliCation For BIOg.Dept� �n I oC_�J 1 ( <br /> PUBLIC WORKS PERMIT PublicWoiksfee <br /> Talal Fee S <br /> Less ApO��Fee Paia S <br /> Print or Type Only e��,��e o�e s <br /> N�r Ll )i� � i Q t�'�5 ��1�3 I C'��I-C� S �'�.FY�z�I � <br /> Owner Mailing Address City 2ip Phone <br /> C l l�l� � C - <br /> Applicant Mailing Address City Zip phone <br /> Describe Proposed Work �1� ��� <br /> Project Address(if known) �1�� ( ��-� � <br /> W � <br /> Attach fout(4)copies of plans lor proposed work-Draw to scaie and note the following as applicable: � <br /> • Property Lines • Centcrline ot street � <br /> � Outline and dimensions of all existing and • Indicate North <br /> proposetl structures on the lot • Show any proposed grading changes <br /> • Existing and p.opused utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE <br /> � PERMITCONDITIONS O <br /> 1.AII calls tor Inspection shall be mede 24 hrs.in advance•phone 259•8870. � . <br /> 2.All work shall be performed in accordance with this permit and current City et Everetl Design and Construction <br /> Standards and Specificatlons. <br /> � 3.Cell Location Underground Sen�ice 48 hrs.betore you dig.TOLL FREE NUMBER 1•800�424•5555. � <br /> RC_'>� ��vi�D � �9/� � <br /> � � <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less the City of Fverett irom any and all claims for damages, costa <br /> expenses, or causes of action that may arise because of installation <br /> and maintenanCe of the improvement or other right-of-way use hereto <br /> applied for and further agrees to remove same upon notice Irom the <br /> Approved for Construction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved as Constructed Signature ol Apulicant Date <br /> everetl PUBLICWORKSDEPARTMENT WORK HUTHORIZED BY TH�S PERMIT MUST BE STARTED WITHIN <br /> � 3200CetlarStreet 180 DP.Y� OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLFD BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 D4YS DURATION. <br />