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DatF—/-zW7 � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mailing Aud—S <br />22 � <br />Applicant <br />Describe Proposed Work <br />public Works Peffelt ezq4- v--- <br />Bid% pilot. - <br />0. C) <br />public Wocks Fee <br />T,bil Fee <br />Less APP� Fee Feld $ <br />B.1ance Due $ <br />r'Ir I <br />Project Address (if known) kA—dr-j <br />d work - Draw to scale and note the following as applicable: <br />Attach four (4) copies of plans for propose * 6enterline of street <br />0 Property Lines 0 Indicate North <br />0 Outline and dimensions of all existing and 0 Show any proposed grading changes <br />proposed structures on the lot 0 Show measurements <br />0 Existing and proposed utilities <br />--- .,,7,i,iFr —Ppi OW THIS LINL <br />-7,1 0'7-z- <br />Phone <br />PERMIT CONDITIONS I be made 24 his, in advance , phone 259,8815. on.,truction <br />1. All calls for inspection shall I, permit and current City of Everett Design and , <br />2. All work shall be performed in accordance with th -5555. <br />Standards and Specifications, <br />3. Call Location Underground Service 48 hrs. before you dig, TOLL FREE NUMBER 1 -900-424 <br />'11 ":' <br />A4AJ se�or <br />;,'-i � a'D <br />. 1% re-y. ia u. 61:4 1 0 <br />7 -jFy <br />­A�; �1,ved for onstru� ion <br />3 <br />Date <br />FIITAi INSPLUIIUN <br />Approved as Constructed <br />ieverett PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />e Phone; 259-8815 <br />ca <br />0 <br />n <br />z <br />0 <br />Cl) <br />0 <br />an <br />ACKNOWLEDGEMENT OF CONDITIONS save harm - <br />The undersigned owner/applicant hereby agrees to hold and <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because Of installation <br />and maintenance of the improvement or other right,ol-way use hereto <br />a ppli for and I ther agrees to remove same upon notice from the <br />n.d tnr of e public pr9pertA da/aged thereby- <br />E�Ignature.liit�ppllcam BY T/ WITHIN <br />WORK AUTHORIZED �PEPMIT MUST LIE STARTED <br />18() DAYS, OF DATE PEF1 IT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION <br />H 1— <br />.3 <br />0 <br />(T <br />U <br />