4001 NASSAU PL 2016-01-01 MF Import

�1 �' , �' Date�] Application For PUBLIC WORKS PERMIT Print or Type Only Address Mailing Address Gliy PUEIit Woeks PermO � _�, �f ama. ooa�.• —�� x+-5a-- Puellc worAc Fee Totel Fae S — Less Poo� f e� Pela S UO BalancnDuo s �� — (L�� a1- 7/RG _ Zip Phone Describe Proposed Work �%P u 1 .S i n� *A WI � �I.1 � 0 I11 P Lof /l /�1n� O� �'✓os�pu. I�i euJ irc c�S Pro�ect Address (if known) Attach lour (4) copies ol plans for proposed work • Draw to scale and �ote ihe tollowing us applicable: • Property Lines • Outiine and dimensions of all ezisting and proposed structures on the lot • Existing and proposed utilities I�� � Centeriine of slreet • Indicate North • Show any proposed grading changes � Show measurements PERMIT CONDITIONS 1. Alt calls for inspection shall be made 24 hrs in advance • phone 259•881 5. 2. All work shali be performed in accordance with this permit and current City of Everett Design and Construction Standards and Specifications 3. Call location Underground Service 48 hrs. betore you dig. TOLL FREE NUMBER 1-800•424•5555. ' %„/n /�z�8 � Approved for Con ruction Date , , �� f-�z Fl�j{p'_ CTION Date Approved as Constructed everett PUBLIC WORKS DEPARTMENT Q 3200 Cedar Street Everett, WA 98201 �� Phone:259•8815 P.CKNOWLEDGEMENT OF CONDITIONS � O � � O a The undersigned uwner/applicant hereby agrees to hold and savc harm- less the City ot Everett Irom any and all „laims for damages, costs, expenses, or causes oi aclion that may arise because of instatlation and maintenance of the improvement or other righFof-way use hereto applied br and further agrees lo remove same upon notice Irom the City and to replace public pro rty damaged thereby. � � � �� -- r�� 5ig ature of Applicant Dale WORK AUTHORI2E0 OY THIS PERMIT MUST BE STARTED WITHIN 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO BE DIL�GENTLY PURSUED TO COMPLETION. THIS PERA1IT MAY BE CANCELLED BY THE CITV UPON ANY STOPPAGE OF WCRK ON THIS PROJECT OVER 90 DAYS DURATION.