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Datelf�'I/ �g' <br />� , Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />owner <br />JaYV� <br />Mailing Address <br />PuULc Works Pormil • �O � 2 3 <br />Blae Dao� • _ <br />Public Wo�ks Fee <br />Tolal Fae s _ <br />�ess AOP�. Fee Peia s <br />Balance0ue S �Q� <br />City Zip Phone <br />Describe?roposedWork 51V1C�'�e 'FSYV�\�l,l �(P_51deV�C'� <br />Prolect Address (if known) <br />Attach four (4� copies ol plans for proposed work • Drew to acale and nole Ihe lollowing as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />FINAL INSPI <br />Approved as <br />everett <br />e <br />• Centerline ot street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measuremeiits <br />PERMIT CONDITIONS <br />1. All cells tor inspectlon shell be madr 24 hrs. in advance • phone 259•881 O. <br />2. All work shall be peAormed in eccordance with this permit and current City ot Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs before you dig. TOLL FREE NUMBER 1-800-424-5555. <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar 9tree1 <br />Everett, \NA 98201 <br />Phone:259�8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees lo hold and save harm- <br />less the City ol Everett trom any and all claims for damages, costs, <br />ezpenses, or causes of action that may arise because of installation <br />and maintenance ol ihe improvement or other righFof�way use hereto <br />applied for and furiher agrees to remove same upon notice Irom the <br />Citv and to repl:�ce public properly damaged thereby. <br />`� '� � <br />Date d�� � /` � <br />Signature ol Applicant Date <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STAHTED WITHIN <br />180 CAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUF.D TO COMPLETION. THIS PERMIT MAY BE <br />CANCEILED BY THE CITY UPON ANY STOPPAGE UF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />