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Date �z_li_�1 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />-Sa m � <br />Applicant <br />Mailing <br />Mailing <br />Pu�IlcWorkSPermil• `�• / �O� <br />aiae� oeo�. � R r- i 9 z 9a <br />PuElic Works Feo <br />Tolal Fee $ <br />Loss ApP� Feo PeiE $ _ <br />BalancoDue S ���� <br />w�Nk -5��-7�f7� <br />���-R9a � <br />DescribeProposedWork YIp� 9irtplp �� �t �r� fP 'rle�rr J�� I���jPr�c�� <br />P��lect Address (if known) <br />Attflch four (4) copies of plans for proposed wo�k - Draw io acale antl note ;he following as applicable: <br />• Proper:y Lines • Centerline of street <br />• Outline and dimensions ot all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show mPasurements <br />PERMIT CONDITIONS � ��D <br />7. All calls for inspection shali be made 24 hra in advance - phone 259�8$�Jr. <br />2. All work shall be performod in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications <br />3. Cail Locatinn Underground Service 48 hrc. before you dig. TOLL FREE NUMBER 1•$00-424•5555. <br />� :G�,�,� /�S/8� <br />Approved tor Cons uction Date <br />.��.0 -l�-���� � —/al - S'd <br />FINAL INSPECTION Date <br />Approved as Conslrucled <br />everett PIiBLIC WORKS DEPARTMENT <br />� 3200 Cedar Slreet <br />Everetl, WA 98201 <br />Phone: 259�8815 <br />ACKNOWLEDGEtviENT OF CONDITIONS <br />The undersigned owner/applicant hereUy agrees to hold and save harm- <br />less the City of Everett irom any and a�l claims lor damages, costs. <br />expenses, or causes ot action Ihat may arise becuuse o� installalion <br />and maintenance ol thA improvement or other righPol•way use hereto <br />applied lor and further agrees to remove same upon nolice Irom the <br />Ciry and to replace public property damaged thereby. <br />,� ` .�i / <br />Si ture ol AppA�a t �e <br />WORK AUTHORIZED BY THIS PERMIT MUST 8E STARTE WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />8E DILIGENTLY PURSUED TO COMPLETION. THIS PEF'MIT MAY BE <br />CANCELLED BY THE C�TY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. �� <br />