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r <br />Date `f�3Q�f3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�Fk� Wi S�� Il Cc�n�>,� ��- <br />Owner <br />?�{'�1 �'1o�vf'_.�e (��`� j:� <br />Mailing Address City <br />PAailing Address Ciry <br />Describe Proposed Work N l.�l' ��"GY.�� ; i.. S�(� ; r� <br />(�i l\ � O � � V� Yl :\ � i�. d �-` f�Y1 i Y1 . V��CT •�_�� <br />Proiect Address (il known) <br />Public Wa�ks Pcrm I• V� �`� <br />eioo 000e. �..3� /%0 <br />auoiic woiks Fee �_ �^j --� <br />Total Fee $ <br />Less ApPL Feo Paitl S � <br />Balenco Due $ ��'� <br />�_: <br />ZiP Phone <br />Allach four (4) copies of plans lor proposed work • D�aw to scale and note the following as applicable: <br />• Property Lines • Centerline of sireet <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />t. All calls lor inspection shall be made 24 hrs. in advance - Fhone 259-881 5. <br />2. All work shalt be performed in accordance with ihis permit and current Cily ol Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUM6ER 1•800-424•$555. <br />FINAL INSPECTION \ <br />Approved as Constructed <br />everett PUBLIC WORKS C <br />� 3200 Cedar Slreet <br />Everett, WA 98201 <br />Phone: 259-8815 <br />I I 4(/ <br />Date <br />m <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />iess the City of Everelt 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-obway use hereto <br />applied lor and further agrees to remove same upon notice from the <br />City and to replace public �roperty damaged thereby. <br />��xu�Yl �� �����s%;t� <br />Signat r of A plicant Dale <br />WORK AUTHORI2ED BV THIS PERMIT MUST BE STAFlTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND Tl1EREPFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BV THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUR�TION. <br />'1 <br />J <br />1 <br />'1 <br />J <br />� <br />�� <br />