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Date���� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />th <br />Applica�t <br />Zip <br />Pu�lm Woda Parmit a �. / <br />BIEO� OeD� • -W— <br />Publm Wo�ks Fee S <br />Totel Feo <br />lese RpP� Fee PeiJ $ <br />Balance0oo S <br />Z5�- <br />Describa Proposed Work �-[' Nd A Y- i+u �]f��i...U�_uA �D �� /a7- YYI �C�F�& ! �-(� �E <br />Proiect Address (if known) <br />Attach four (4) copies ot plans for proposed work - Draw to scale and note the following as applica6le: <br />• Property Lines <br />� Outline and dimensions ol all eristing and <br />proposed structures on the lot <br />• Existin9 and proposed utilities <br />• Centerline �I street <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. A�I cells for (nspection shall be made 24 hrs. in advance - phone 259•881 O. <br />2. All work shell be performed in accordence with this pe�mit and current City of Everett Design and Construclion <br />Stendards and Specifications. <br />3. Cell Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800-424•5555. <br />PU3G/C LJOL.e-s �,��e'�iT,lJOT ,Q,� . <br />Approved for Construction Date <br />FINAL INSPECT�ON <br />Approved as Construcled <br />evcrett PUBUC WORKS DEPAaTMENT <br />� 3200 Cedar Sireet <br />Eve�elt, WA 98201 <br />Phone: 259-8810 <br />Date <br />a a�-a� <br />'/� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned ow�er/applicant hereby agrees to hold and save harm� <br />less the City ol Everett Irom any and all claims lor tlamages, costs, <br />expenses, or causes of action that may arise because ol installation <br />and maintenanCe of the improvemenl or other right•of-way use herelo <br />applied for and furlher agrees lo remove sa�ne upon notice Irom the <br />City and to replace public properry damaged thereby. <br />Signature ot Applicanl Date <br />WORf:.4UTHORIZED BY THIS PERMIT MUST BE STARTEO WITHIN <br />180 DAYS OF UATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENT�Y PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLFD BY THE CITY UPON ANY STOPPAGE OF WOFK ON THIS <br />PROJECT JVER 90 DAYS DURATION. <br />