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Date-�_ f�`�' - <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />I2� Z NG <br />Mailinq Addrese <br />ApFlican��� Mailing Address <br />Describe Proposed Work <br />City <br />.� <br />Zip <br />b'3 i �6/ <br />Publtc Wa�ks Permit + <br />ew9. oeo�� • <br />Pu01ic Works Fee $ "� � Q Q <br />Tolni Fee <br />Less ADPL Fee Peld $ � O OO <br />Balnnce Duo S <br />Project Address (if known) ' ' <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed siructures on the lot <br />• Existing and proposed utilities <br />• Centerline of street <br />• Indicate tJorth <br />� Show any proposed grading changes <br />• Show measurements <br />'36Z6"�"� <br />,' l,�lZ h�or..-� <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259-881 5. <br />2. Ali work shall be performed in accordance with lhis permit and wrrenl Ciry of Everett Design and Construction <br />Standards and Specificationa <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•�24'55� <br />`7'. �004- �ra�v�� w�v�s�- �oe -�� 5�..�- ��,:���/ <br />. <br />�jetv�. a�� <br />S� � <br />(70 � � o.-. eo...�� <br />5ew2�% <br />�„�o� � � b e „�. s�a l l c�/ <br />-�,�I t o-�' a-l� -� <br />e �,� �,n i o:-. o�4- <br />� <br />�n e c e g Sa <br />Approved tor Construction Oate <br />; '� � Y <br />r� r,� �� G��--. S. z• F <br />FIN7CL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Streel <br />Everelt, WA 98201 <br />Phone: 259•8875 <br />�Pe� s <br />W <br />H <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />a <br />� ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everelt irom any ond all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvem=nt or other righFof-way use heretn <br />applied for and lurther a�rees to remove same upon notice irom the <br />Ciry and to rep�ace public properry damaged thereby. <br />��� �'I�--. <br />Date <br />Signature of Applicant <br />80RDA STOFRDATE PERMIT ISEISSUED ANDBTHEREAFTER ISHTO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORrC ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />