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��x <br />C, H <br />9HxN <br />HZ� <br />FC f7 <br />H� <br />���H� <br />OHd <br />��g <br />�V n <br />t'y� <br />Hy <br />gy <br />H <br />C� t! V� <br />�H� <br />HO[n <br />Date�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />0 <br />City <br />r�ei�c wo�xa ro�� �i y pU����-7 /�� <br />omB. 000�. • O�.L/� <br />Puboc WmAa Fon S <br />Total Fee <br />�essnoo�. Fcc va�e 5 z� <br />9alancoDm $ � <br />Phone <br />�/���'LP <br />Applicnnt Mailinq Adtlress City Zip Phone <br />Describe Proposed Work ' LY�� � ��Cr � <br />Projec� Address (il known) <br />Attach four (4) copies ol plans lor proposed work • Dravi to scale and nole lhe lollowing as applicable: <br />• Property lines .• Centerline ol street <br />• Outline and dimensions ol all existing and • Indicate Norih <br />proposed struclures on the lot • Show any proposed gradin9 chnnges <br />• E:isting and proposed utilities • Show measurements <br />1 <br />PERMIT CONDITIONS <br />1. All calls for inspeclion shall be made 24 hrs. in advance • phone 259•881 5. <br />2, All work shall be perbnned in accordance with ihis permil and current Ciry ol Everetl Design and Construction <br />Standards and Specilica�ions. <br />3. Call Locatlon Underground Service 48 hrs. before you dig. TOIL FREE NUMBER 1-500•424•5555. <br />STREETS ARE TO BE KEPT CLEAR OF ALL MUD�GRAVEL�AND MISC. DEBRIS AT <br />ALL TIMES, <br />FAILURE TO KEEP THE PUBLIC R.O.W. FREE OF DEIIRIS AND/MUD OR GRAVEL <br />WILL RESULT IN THE IMMEDIATE POSTING OF A STOP WORK ORDER ON THE <br />PROJECT WHICH WILL REMAIN IN FORCE UNTIL ALL CLEAN UP OF THE R.O.W. <br />IS COMPLETED TO THE SATISFACTION OF THE PUBLIC WORKS INSPECTOR <br />i���% /� Y' � �% <br />mroved lar, o ction Date <br />:'� �� ' � 3_02,2 �f'� <br />JAL INSPECTION Date <br />xoved as Constructed <br />rverett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everetl, WA 98201 <br />Phone:259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />N <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the Ciry of Everett Irom any and all claims foi damages, wsts, <br />ezp@n5@5, Of Cau505 OI action ihat may arise because ot inS�allation <br />and maintenance of the improvement or olher righ4oFway use hereto <br />applied lor and lurther agrees to remove same upon notice Irom ihc <br />City and to replace public property damaged thereby. <br />��r <br />��i�i / /C7 ' / — �'7 <br />Signalure ol�icant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PER�41T MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />