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Date_�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />n, <br />� <br />aaaress <br />Describe Proposed Work <br />Prolect Address lil know�l <br />City <br />Uly <br />� <br />Attach four (4� copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Pwperry Lines <br />• Outline and dimensions of a�l existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />Pub6c Worka Permll � � � � <br />emo oeo�.. _�' ��,� � <br />PWI¢ Wo�As Fcc <br />Tolal Fca S _ <br />Less Pppt Fee Pa�J $ �J <br />Balanca Due S G Q�— <br />• Centerline o( street <br />• Indicate �orth <br />• Show any Vroposed greding changes <br />• Show measuremenis <br />?—da 3 - <br />PEFMIT CONDITIONS <br />1. All calls for inspectio�� shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Constructlon <br />Standerds and Specifications. <br />3. Call Location UndergrounA Service 48 hrs. before you dig. TOII FREE NUMBER 1•800-424•5555. <br />;�. �C�07�� L��i�t't�7�Zj� ` 4�xd� �2eG�'-m�� <br />-,?� 2'u,t.G- r.r.�-4' /L.� � �-�� a.n.�� <br />,d'� 3D5 �•-a� �'3�6 . <br />S ��,a�a� �tu� a��i� �i �tR"�c�i�c� �307 � <br />�2P�� S.�ct!-o�+� .� 3 7 � .�.� � d�2'�i��� �ia�w�� <br />���i���� �v� S��BB <br />Approved for Constr�ytion Date <br />. // <br />� / /.)-.%'�� <br />FINA NSPECTION Date <br />Approved as Consiructed <br />everett PUBLIC WORKS OEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259�8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hcld and save harm• <br />less the Cily of Everetl Irom any and all claims for damages, costs, <br />expenses, or causes of action Ihal may arise hecause of inslallation <br />and mainlenance ol the improvement or other right�ol�way use hereto <br />applied or and furlher agrees to remove same upon nc+tice Irom the <br />City a ro replace pubGc property damaged thereby. <br />' <br />SI n ure f ApP�� t Date <br />WORK UTHOR [D BY THIS PERMIT MUST BE STARTED WITHIN <br />180 0.4YS OF DATE PERMIT IS ISSUED 1ND THEREAFTER IS TO <br />BE DILIGENTLY PURSUEG TO COMPLET�ON. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 OAYS DURATION. <br />